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Medical and Surgical 


Harold H. Kynett, A. M., M. D. 



Philadelphia : 
P. 0. Box 843. 


AXTELL, J. t., M. D. 


BAKER. 0. C, M.D. 



BENNETT, T. J., M. D. 


BLACK, A. J., M. D. 


BURR, WM. H., M. D. 

BUTLER, F. P., M.D., Marshaltown, Iowa. 

CURRIE, M. L., M. D, 



EVARTS, ORPHEUS, M.D., College Hill, Ohio. 

FENNER, E. D., M. D. 

GOOGE, W. R., M. D. 

HAPPEL, T. J., A. M., M. D. 
HOWLETT, K. S., M. D. 


JUDSON, A.B., M. D. 

KEEF, P. 0. 


LATTA, S. W., M. D. 
LINK, W. H., A. M.. M. D. 

MASON, A. L., M. D. 

McMURTRY, L. S., M.D. 
MOORE, C. C, M. D. 

NUTT, G. D., M. D. 

PALMER, P. C. M. D. 





PELTON, D, B., M.D. 

PHELPS, A. M., M.D, 


PRICE, W. HENRY, B. A., M. D. 


POTTS, B. H., M.D. 

PUNTON, JOHN, M. D., Kansas City, Mo. 





SHERWOOD, MARY, M. D., Baltimore. Md. 







THOMAS, G. D., M.D. 

TOWLER, S. S., M. D.. Marionville, Pa. 





VOJE, J. H., M. D., Oconomowoc, Wis. 




WHITE, J. WM., M. D. 

WIG GEN TON. R. M., M. D. 

WILCOX, F. W., M.D. 





WRIGHT, J. S., M. D. 



Abdominal Hj'Stereetomy without a Pedicle, with re- 
port of ten Consecutive Cases, Rubus B. Hall., M. D,, 
Cincinnati Ohio, 100. 

Pain Following Typhoid Fever, 282. 
Surgery by Untrained Operators, with Deficient 
Appliances, J. McFaddon Easton, M. D., 
Atlanta, Pa , 360. 
Abnormal development of the Teeth Forming Tumors 

of the Jaw, 145. 
Abortive treatment of Buboes, 772. 

Treatment of Gonorrhoea, 772. 
Absence of Gentials; Vicarious Bpistaxis, 622. 

Of the Liver, G. Frank Lydston M. D., Chicago 
111., 849. 
Actinomycosis cured by Potassium Iodide, 996, 
A Case of Senile Gangrene Treated by Amputation 

G. W. H. Kemper, M. D., Muncie, Indiana, 638. 
A Committee on Drink, 912. 
Acquired Syphilis in Childhood, 882, 
Action of Bicarbonate of Sodium on Digestion, 878. 
Of Pilocarpine on Bodily Temperatures, 700. 
Acute Intestinal Obstruction Treated by Laparo- 
tomy, 52. 

Ulcerative Endocarditis Due to Bacillus of Diph- 
theria, 69. 
Administration of Milk by Accurate Dosage, 956, 
Additional Note on treatment of Exophthalmic 

Goiter, 63. 
Address in Medicine, S. W. Latta, M. D., Philadel- 
phia, 446, 

In Obstetrics, Thos, D. Dunn, M. D., West 
Chester, 449. 
Adenoids, a Factor in Aural Affections, 795, 
A. Departure in the Treatment of Bright's Disease, 

W. H. Walling, M. D., Philadelphia, 749. 
Administration of Anaesthetics, 700. 
Advantages of a Physician Dispensing his own Medi- 
cine, 660. 
Affections of the Labyrinthine Capsule a Frequent 

Cause of Deafness, 788, 
A Medical Objection to Dancing, George L. Beardsley, 

A. M,, M. D., Birmingham, Conn., 479. 
American Inebriate Asylums, 420, 562, 
Amputation for Diabetic Gangrene. 919. 

Of Leg. 288. 
Anaesthesia, Wm. H. Barr, Wilmington, Del., 110. 
Anaesthetics, George Foy, Dublin, 216. 
Analysis of one hundred and twenty-five Cases of 

Hernia, 58. 
Announcement— College of Physicians of Philadel- 
phia, 385. 
Anthrax, 693, 

Bacilli in Mud at Bottom of Well, 761. 
Antidote for Carbilic Acid, 384. 
Antiseptic Intra-Pieural Infection, 427. 

Treatment of Burns in Children, 881. 
Treatment of Ozena, 620. 
An Unusual Case of Hemorrhage of the Uterus,CIara 

T. Dercum, M. D., Philadelphia, 637. 
A Peaceable Race, 455. 
Appendicitis, 288,771, 

And its Complications from a Surgical Stand- 
point, 187, 458. ^ 
What it is and what it is not from a Surgical 

Standpoint, 55. 
What it is and what it is not. from a Surgical 
Standpoint, Joseph Hoffman, M. D., Philade- 
phia, 303, 

Arsenic Internally in Cancer, 866. 

Arsenical Neuritis, 154. 

Artificial Delivery in Copenhagen, 582. 
Diamonds, 190. 
Opening of Pulmonary Cavities, 56. 

Asthma, 995. 

Ascites — its Treament from a Gynecological Stand- 
point, 909, 

A Serious Gun-Shot Wound of the Thigh With- 
out Hemorrhage, A. 0. Stimpson, M. D., C. M. 
Thompson, Pa., 719. 

Asiatic Cholera in England, 57B. 

Association of Diseases and Morbid Processes, 64. 

ATableof Food Values, 655. 

A Treatment for Fistula in ano Without a Cutting 
Operation, T. J. Bennett, M. D., Austin, Texas, 364. 

Aural Vertigo, Meniere's Disease. 

Auscultation in Fractures, 520. 

A Year's Work in Minor Gynecological Surgery, 
Charles P. Noble, M. D., 824. 

Bacilli and Nitric Acid, 634. 

Bacillus of Diphtheria (Klebs' Loeffler Bacillus), 68. 

Bacteria in the Soil at different Depths, 374. 

Bacteriology and Country Hygiene, K. S. Howlett, 
M. D., Bigbyville, Tenn., 7. 

Bathing After Exercise, 580, 

Bi-Cornate Uterus;';Placenta Previa; Caesarean Section, 
William Varian, M, D., Titusville, Pa., 478, 

Biographical Sketch of the Late Isaac Kerlin, M. D., 
Laurence Turnbull, M. D., Ph. D., Philadel- 
phia, 829. 

Blood Changes in Syphilis, 309, 

Bloodless Amputation at Hip Joint, 77. 

Blood-Letting as a Therapeutic Agent in the Treat- 
ment of Diseases, J. S. Dukate, M, D., 585, 

Blood Pressure, Wm. Bailey, M. D,, Louisville, 
Ky„ 277, 

Blood Pressure, 331. 


A Chapter on Cholera for Lay Readers : Walter 
Vought, Ph. B,, M. D., 990, . 

A Manual for Boards of Health and Health 
OflBcer-s, Lewis Balch, M. D., Ph, D., 462. 

An American Text Book of Surgery for Practi- 
tioners and Students, 461. 

An Introduction to Study of Diseases of the Skin, 
H. H. Pye-Smith, M. D., F. R. S., F. R. 
C.P., 268. 

A Standard Dictionary of English Language, 35, 

A System of Genito-Urinary Diseases, Syphilology, 
and Dermatology, 842, 

A Text-book of the Theory and Practice of 
Medicine, By American Teachers, 731. 

Cholera, Dr. G, Archie Stockwell, F. Z. S., 990. 

Clinical Lectures on Abdominal Hernia, Wm. H. 
Bennett, T. R. C. S., 731. 

Cosmopolitan for November, 732. 

Diseases of the Nervous System, Dr. Ludwig 
Flint, 35, 

Diseases of the Rectum and Arms, Charles B, Kel- 
sey, A. M., M. D„ 732, 

Duane's Students Dictionary of Medicine, Alexan- 
der Duane, M. D, 

Dungleson's New Pronouncing Medical Diction- 
ary, 384, 



Electro-Therapeutics of Neurasthenia, W. R. llob- 
inson, M. D., 990. 

Hospitals and Asylums of the World, H. C. Bur- 
dett, 383. 

Les Troubles du Language Chez Les Alienes, 
J. Seglas, 952. 

Manual of Bacteriology for Practitioners, Dr. S. 
L. Schenk, 951. 

Materia Medica and Therapeutics, John V. Shoe- 
maker, 2 vols., 36. 

Recent Developments in Massage, Douglass 
Graham, M. D., 990. 

Review of Reviews, 384. 

Sharp & Dohme's Price List for 1893, 384. 

Somsino, P. Sviluppo, ciclo vitale e ospite inter- 
mediodella Bilharzia hsematobia, 843. 

Surgery and Surgical Anatomy of the Ear, Albert 
H. Tuttle, M. D., 35. 

System of Diseases of the Ear, Nose, and 
Throat, 732. 

Text Book of Normal Histology, George A. Pier- 
sol, M. D., 951. 

The Health Resorts of Europe, Thomas Linn, 
M. D., 731. 

The Medical News Visiting List for 1894, 842. 

The Ready-Reference Hand-Book of Diseases of 
the Skin, George Thomas Jackson, M. D. 

The Theory and Practice of Medicine Prepared for 
Students and Practitioners, James J. Whittaker, 
M. D., L. L. D., 804. 

Various Forms of Hysterical or Functional Par- 
alysis, H. Bastion, Charleston, M, A., M. D., 
F. R. S., 268. 

Brain Surgery, 56. 

Brief Clinical Memoranda, 63. 

Bright's Disease, John M. Batten, M. D., Pitts- 
burg, 6«]. 

Bromide of Potassium for Invagination, Harvey Van- 
netta, M. D., Seal, Ohio, 294. 

Bromoform in Whooping Cough, 868. 

Broncho-Pneumonia, J. C. H.Lawrence, M. D., Green 
Bay, Wis., 522. 

Caffeine Chloral, 228. 
Calomel in Gout, 619. 

Soap in the Treatment of Syphilis, 660. 
Cancer of Rectum, 373. 

Carbolic Acid used in Full Strength in Surgery, 860. 
Care of Catheters, 772. 

Of Upper Air Passages in Treatment of Syph- 
ilis, 176. 
Case of Puerperal Eclampsia, 948. 
Cause Which Determines Sex, 148. 

Cerebro Spinal Architecture as a Factor in the Diag-« 
nosis of Nervous Diseases, John Punton, M. D , 
Kansas City Mo., 1 

Spinal Meningitis, 540. 
Chancre of the Mouth, 910. 
Changes and Degenerations in Naevi, 919. 

In the Cardial Ganglia in Acute aud Sub-Acute 
Endocarditis, 308. 
Chemical Antidote for Cyanide of Potash, 800. 
Chlorate of Soda in Cancer of the Stomach, 836. 
Chloride'of Ammonia in Cystitis, 800. 

Of Gold and Sodium in Bright's Disease, 692. 
Of Iron in Diphtheria, 153. 
Chloroform as a Tape Worm Remedy, 620. 

Anaesthesia and its Administration. Part Sec- 
ond, 207. 
Mortnlity in Australia, 879, 
Cholera, Earnest Hart, London, 46. 

And its Management in Hull, England, 682. 

Bacilli in Dust, 661. 

Infantum and its Treatment. Manuel Septien, 

M. D., Quevetaro Mexico, 671. 
Its Prevention and Treatment, 378, 
Cholecystotomy, 257. 

Chronic Diarrhoea, Insomnia, Attempted relief by 
Hynotism, Erythema, Nodosum, 254. 

Glanders Terminating Fatally in Acute Ex- 
acerbation, 534. 
Cicatricial Stricture of Pylorous, Pyloroplasty, A. M. 

Cartledge, M. D., Louisville, Ky., 745. 
Classification of Arteritis, 186. 
Cleft of the Hard and Soft Palates, J. Ewing 

Mears, M. D., Philadelphia, 966. 

Clinical Course, Diagnosis, and Structure of Cancers, 

955. ^ 

Clinical and Etiological Observations of Psoriasis, 761. 

Aspects of Pneumonia in Children, Henry E. 

Tuley, M. D., Louisville, Ky., 361. 
Observations in Philadelphia, W. H. Link, 

M. D., Petersburg, Ind., 97.^ 
Regions of the Abdomen, 828. 
Report of a Case of Hepatic Abscess, A. J. 

Block, M. D., New Orleans, La., 371. 
Thermometers, 459. 
Cocaine and the Milk Secretion, 770. 

In General Medicine, 220. 
Cold Abscess of Foot; Underlying Tuberculosis of Tar- 
sus,- Amputation of Leg; Tubercular Arthritis of 
Knee; Amputation of Thigh, Rosewell Park, A. M., 
M. D., 317. 
Collection and'Disposition of Animal and Vegetable 

Waste in Milwaukee, 681. 
Complications of Vaccination, 956. 
Combined Effects of Morphine and Sulphonal, 466. 
Complete Reunion of Severed Fingers, 582. 
Compound Dislocation of Left Ankle and Fracture of 
the Internal Malleolus — Astragalus and Internal 
MallelousExcised, Charles B. Williams,A. B., M. D., 
Philadelphia, 131. 

Fracture of the Skull, 60. 
Conception on the Fourth Day of Child-bed, 78. 
Condition of Spinal Ganglia in Tabes Dorsalis, 153. 
Conservative Operation of the Ovaries, Tubes and 

Uterus, 543. 
Considerations Bearing on Treatment of Pneu- 
monia. 51. 
Constipation, 134. 

Consumption of the Lungs is not to be Compared with 

Leprosy, Samuel G. Dixon, M. D., Philadelphia, 758. 

Continued Report — Tumor in Epigastric Region, 

Contra-Indications and Indications for Sea-bathing 

Children, 980. 
Continued Report, 415. 

Contribution to the History of the Discovery of Mod- 
ern Surgical Anaesthesia, with New Data Relative to 
the Work of Dr. Crawford W. Long, Luther B. 
Grandy, M. D., Atlanta, Ga., 646. 

To the Operative Treatment of Congenital Hip- 
Joint Dislocations, 530. 
To Pathology of Experimental Diphtheria with 
Special Reference to Appearance of Secondary 
Foci in Internal Organs, 69. 
To the Statistics of Renal Surgery, Dr. James 

Israel, 515. 
To the Study of Yellow Fever From a Medico- 
Geographical and Prophylactic Point of View 
in the Mexican Republic, Edwards Lieeage, 
M. D., Mexico, 701. 
Convulsions, 840, 

Correction of Syphilitic Deformity of Nose ; Syphilitic 
Stenosis of Larynx; Amputation of Leg on Account 
of Compound Dislocation of Ankle; Torticollis 
Collar; Removal of Breast for Cancer, Roswell Park, 
A. M., M. D., Buffalo, N. Y., 512. 
Coughs in Children, W. Henry Price, B. A., M. D., 

Philadelphia, 780. 
Craniectomy, 883. 

In Idiots, 772. 
Craniometric Measurement in Relation to Aural 

Topographic Anatomy, 796. 
Creolin a Mixture of Carbolic Acid and Resin Soap, 75 
Creosate in Latent Tuberculosis, 869. 



Crying in Children, 349. 

Crystalline a Substitute for Collodion, 836. 

Cystitis, 838. 

Dangers and Avoidance of Ergot in Obstetrics, 922, 
In Antiseptic Midwiferj, 261. 
Of Vaginal Pessaries, 115. 
Deaths from Angesthetics in Germany, 879. 

From Salol,V70. 
Pecline in Consumption of Liquor, 769. 
Demonstration of Gastrodiaphany, 65. 
Dermoid Cyst of the Tongue, 293. 
Destruction of Microbes by Infusoria, 938. 
Detection and Significance of Carbo-Hydrates in the 

Urine, 64. 
Diabetes, 919. 

And Cirrhosis of the Liver, 581. 
In a Baby, 919. 

Insipidis, F. P. Butler, M. D., Marshalltown, 
Iowa, 14. 
Diagnosis and Treatment of Empyema, 0. C. Baker, 
M.D., Brandon, Vt., 784. 

In Diphtheritic Angina, 839. 

Of Inebriety from Apoplexy, 699. 

In Abdominal Tumors; Prolapsus Uteri, E. E. 

Montgomery, M. D., 741. ;■ 
Of Apoplexy, 76. 
Of Epilepsy by the Urine, 665. 
Diarrhoea Caused by Infusoria, 615. 

In Children, J. D, Weaver, Norristown 
Pa., 405. 
Diffuse Gangrene of Left Lung, 995. 
DiflFerential Diagnosis and Treatment of Chronic Ear 
Disease, 344. 

Diagnosis of the Various Forms of Convulsions 
in Young Children, 114. 
Digital Compression in the Vomiting of Anaes- 
thesia, 231. 
Diphtheria and Scarlet Fever at the Boston City Hos- 
pital, 1001.. 
Diphtheria, 64. 

T. J., Happel; A. M., M. D., 79. 
W. H. Burr M. D- Wilmington, Del., 853. 
Discharge of Ascarides by the Umbilicus, 809. 

Of Pus at the Navel following an attack of 
Typhoid Fever, 281, 
Discussion of Dr. Adams' paper, 485. 

Of Paper Surgery of Tubal Pregnancy, W. A. 
O.and G., 525. 
Disease Due to Streptococci, 691. 
In the Sigmoid Flexure, 23. 
Of the Spleen and their Importance, 345. 
Probably Caused by Flies, 261. 
Disorders of Nervous- System Associated with the 

Change of life, 766. 
Disposal of Garbage and Waste of Columbian Exposi- 
tion, 681. 
Disputed Points in Hysterectomy, Joseph Price, A. M. 

M. D., Philadelphia Pa., 11. 
Double Empyema, 581. 
Hydrocele, 750. 

Lesion of the Brain; Cerebral Cyst and Cere- 
bellar Tumors, 560. 
Pyosalpinx, 424, 
Duboisine Sulphate as a Sedative, 799. 
Dyspepsia as a Nervous Disease, 555. 

Early Aspiration in Acute Pleuriti?. 64. 

Management of Club-foot, 771. 

• Removal of Tubercular Foci of Bone. B. Merill 
Rickets, M. D., Cincinnati, 0., 200. 

Treatmentof the Insane, 338. 
Ectopic Gestation in Both Tubes, 424. 


Does the AtBerican Medical Association Need a 

Medical Journal, 30. 
Echoes From the Pan-American Congress, 564. 

Hard Times and Free Medicine, 642. 

Identity of the Streptococcus Pyogienes and the 
Streptococus Erysipelatis, 944. 

Immunity and Tetanus, 759 

Inebriety and its Treatment, 336, 

Injudicious House Quarantine, 456. 

In Memorium, James McCann, M. D , L. L. D., 

Law Warrants and the Doctors, 503. ' 

Local Medical Societies, 797. 

Maternal Impressions, 27 . 

Medical Association, 105. 

N. B., 979. 

Peritonitis Caused by the Proteus Vulgaris, 217, 

Practical Quarantine, 417. 
Preventive Medicine, 66. 

Responsible Cranks, 832. 

Retrospective, 0000. 

Should the Practitioner Supply his own Medi- 
cine. 945. 

Specialism in Medecine,295. 

St. Anthony — up to the Date, 905. 

Tetanus: Its Cans- and Cure, 184. 

The Doctor and the Cook, 526. 

The Pan American Congress, 689. 

The Pan-Ameri-an Medical Congress, 416. 

The President's Health, 375. 

The Prevention of Surgical Infection, 142. 

The Real Versus the Ideal in the Practice of 
Medicine, 863. 

Trichinosis and Meat Inspection, 259. 

The Physician in Relation to Courts of Justice, 

Use and Abuse of Public an i Private Chari- 
ties, 605. 

Effect of Pilocarpine in Changing Color of Hair, 917. 
Of Removing the Ovaries, 156. 
Of Smoking Tobacco on Boys, 188. 
Effect on Sucklings of Purgatives Administered 

to the Mother, 957. 
Electrolysis in Fibrous Ankylosis, 464.- 
Embolism of the Popliteal Artery Following Diph- 
theria, 580. 
Empyema — Resection of Rib without Angesthesia, 182. 
Engleman (R) on Sti dy of Accidents of Vaccina- 
tion 957. 
Enchondroma of the Mammary Gland in a Bitch, 660. 
End-to-End Anastomosis, 55. 
Enucleation of the Eye. 773. 
Epilepsy, 580. 

Epileptic Neuralgia of the Face, 231. 
Epistaxis, 72, 

Ergotine and Gallic Acid in Hemoptysis, 621, 
Errors that may Arise in Measuring the Length of the 
, Lower Limbs, J, S. Wight, M. D., 650. 
Erysipelas, 869. 
Esencia de Calisaya, 736. 
Estlander's Operation in Empyema, 426. 
Etiology of Cancer, 966 
Etiology and Prevention of Deafness, George P. 

Keiper, A. M., M. D., LdFayette, Ind., 629. 
Etiology and Treatment of Abortion and Premature 
Labor, 908. 

Of Acute Articular Rheumatism, 607. 
Of the Primary Carcinoma of the Gall Blad- 
der, 529. 
Of Whooping-Cough, 114. 
Ether locally in Incarcerated Hernia, 693. 
Eucalyptus Oil, 769. 

Every Day Surgery, P. 0. Keef, Oconto, Wis., 172. 
Excision of an Hydatid Cyst of the Lung, 427. 
Existence of Pathogenic Bacteria in the Upper Air 

Passages, 865. 
External Urethrotomy followed by Septic" Arthritis, 

E. D. Fenner, M. D., New Orleans, La., 893. 
Extirpation of Aneurisms, 56. 

Of the Spleen for Traumatism, 298. 
Of the Wounded Spleen, 659. 


Extra- Uterine Pregnancy, 662, 921. 
Eye-Paralysis, 699. 

Symptoms of Brain Disease, Charles Zimmer- 
man, Milwaukee, Wis., 166. 

Fads of Medical Men, J. Newton Hunsbereer, 

M. D., 500. 
FataJ Case of Typhoid Fever, 255. 
Fatty Degeneration of the Heart, 608. 

Tumor, 176, 751. 
Fecal Fistula following Hernia, 156. 
First Pan-American Congress, 786. 
Five Cases of Congenital Stricture, 71. 
Focussing Ear Trumpet, 894. 

Foetal Peritonitis Severing the Intestinal Canal, 542. 
Foetal Urine Secreted in Utero, 922, 
Foot and Mouth Disease in Man, 994. 
Foreign Body in the Ear, 765. 
For Obstinate Vomiting of Pregnancy, 596. 
Foreign Substance in the Ear for Thirty Years, C. C. 

Moore, M. D., Philadelphia, 175. 


Absorption Required, 150. 

Acute Bronchitis, 870. 

Acute Coryza, 72 

Acne, 150, 298, 871. 

Acut*" Rheumatism, 223,771. 

Alopecia Circumscripta, 265. 

An Alkaline Tincture, 340. 

An Epilatory in Skin Diseases, 692. 

Antiseptic Varnish, 920. 

Aristol in Hemorrhoids, 132. 

Atrophic Rhinitis, 226. 

Aqua Viaii in Cholera, 226. 

Bee Stings, 868. 

Bites of Insects, 226. 

Bromidism, 150. 

Brown Leather Polish, 150. 

Burns, 267. 

Carbuncle, 29 

Chloroform for Tape-worm, 880. 

Chronic Bronchitis and Emphy ema, 226. 

Cocktail Bitters, 316. 

Constipation in Dyspeptics, 801. 

Constitutional Syphi is, 226. 

Cramps of Legs in Pregnant Women, 305. 

Cutaneous Diseases, 226. 

Deodorizer for Iodoform, 150. 

Diarrhoea 29. 

Diphtheria, 868. 

Dysmenorrhoea, 836, 

Dyspnoea of Acute Phthisis, 838. 

Ecz-ma of Ear and External Auditory Canal, 9. 

Of Vulva, 150. 
Embalming, 15 '. 
Enlarged Tonsils, 226. 
Flatulent Dyspepsia, 29. 
Formulas for Antiseptic Treatment of Boils snd 

Carbuncles, 694. 
Gronorrhoea, 105. 
Good Alterative, 305 

Hardening and Coloring Plaster of Paris Casts,191. 
Hemoptysis, 800. 
Herpes Zo ter, 226. 
Hyperidrosis, 150. 

Hypodemic Injections of Iron in Anaemia, 218. 
Hysteria, SfiO. 
Inebriety, 882. 
Interigo, 305. 

Itching After Eruptive Diseases, 868. 
Label Paste, 185. 
Laryngeal Phthisis, 185. 
Leucorrhoea, 694. 
Liniment for Neuralga, 29. 
Liquid Spice Plaster, 150. 
Local Anaesthesia, 185. 

Sjphilidesof the Scalp, 218. 

Migraine, 199, 868. 

Malignant Lymphoma, 867. 

Naso-Pharnygeal Catarrh of Nurslings, 1' 9, 

Naphthaline in Ta: e W rm, 802. 

Nervine Tonic in Pill Form, 345. 

Nocturnal Sweats of Consumption, 226, 

Night Sweats of Pulmonary Tuberculosis. 29, 

Ovaritis, 883. 

Pain in the Ear, 132. 

Palpitations in Arteriosclerotics, 692. 

Paralysis in Lead Poisoning, 29. 

Pediculosis Capitis, 388. 

Phosphorus in Osteomalacia, 694. 

Pityriasis Rubra, 316. 

Prevention of Boils, 226. 

Pruriginous Affections of the Skin, 868. 

Pruritus, 267. 

Purulent Cystitis, 34. 

Salicylic Acid in Acute Rheumatism, 882. 

Salicylic Acid in Cancer of Uterus, 801. 

Scrotal Eczema, 191, 

Shock following Abdominal Operations, 223. 

Soothing Ointment for Eczema, 342. 

Spice Plaster, 191. 

Stubborn Neuralgia, 340. 

Sub-Acute Stage of Bronchitis, 150. 

Suppositoriesfor Acute Articular Rheumatism, 799. 

Tape-Worm, 150; 

To Hasten Desquamation in Scarlatina, 219. 

Treatment of Comedones, 149. 

Urticaria, 191, 305. 

Vomiting after Etherization, 132. 

Fracture of the Humerus in a Child One Day Old, 72» 

Of Patella, William Mackie, M. A., M. D., 233. 

Of Skull with Protrusion of Brain Substance 

and Removal of Same, W. R. George, M. D., 

Abbeville, Ga., 202. 

Frequency of Sequestra in Tuberculosis of Larg& 

Joints; Treatment of Joint Tuberculosis, 540. 
Further Observations of the Relation of Pelvic Disease 
and Psychical Disturbances in Women, George H. 
Rohe, M. D,, Catonsville, Md., 84. 

Gastr: stomy by Witzel's Method For Primary 
Cancers of the CEsophagus, William W. Keen,. 
M. D., Philadelphia, 923. 

Gangrene Complicating Cholera, 462. 

Of Foot and Leg, B. H. Potts, M. D., Philadel- 
phia, 17. 

Gall-stone Complicated by Gastric Ulcer, W. Henry 
Price, 633. 

Gastric and other Nervous Symptoms of Neuras- 
thenics, 620. 
Ulcers, 348. 

General Body Defo mity with Ankylosis of the 
Spine, 939. 

General Paralysis or Paralytic Dementia, D. R. Pel- 
ton, M.D,, Topeka, Kansas, 243. 

Geological Times, 500. 

Gonorrhoea and the Puerperum, 542. 

Gonorrhoeal Infectionof Mucous Membrane of Mouth in 
New-Born Infants, 155. 

Occurring in Little Girls, 645. 

Haematuria, 383. 

Htemophila and Parturition, 464. 

Heart Failure, 995. 

Headache, 62. 

Versus Glaucoma, W. L. Bullard,M. D., Columbus, 
Ga., 204. 

Heart Disease or Kidney Disease, James Tyson,^ 
M. D., 517. 

Heat and Chloroform, 75. 

Hemianopsia and Certain Symptom Groups in Sub- 
Cortical Lesion, 561. 

Hemiparaplegia, 556. 

Hemiplegia following Injury, 755. 



Hereditary Ataxia, 880. 

Transmission of Immunity Against Rabies from 
the Father to the oflFspring, 660. 
Hernia of the Vermiform Appendix, 645. 
Hints to Prevent the Spread of Consumption, 73. 
Homoeopathists as Vivisectors, 796. 
Horse-hair in Minor Surgery, 774. 
Hot water in Treatment of Corneal Affections, 348. 
How an Epidemic of Pneumonia was Checked, 686. 
How can Women Promote Public Sanitation? 682. 
How Shall the Dispensary Abuse be Remedied, 977. 
How Shall our Lepers be eared for? 687. 
How to give a Fomentation, 272. 
Human Nasal Canals as related to Climate and 

Pulmonary Disease, 856. 
Hydrastis in treatment of Night-Sweats, 881. 
Hygiene of Hair Dressing and Barber Shops, 685. 
Hypodermic Injection of Mercurial oil in Cerebral 

Syphilis, 837. 
Hypnotism and Suggestion, 656. 
Hysterectomy for Cancer of Cervix, 883. 

Ichthyol in Erysipelas, 153, 

In Prostatitis, 619. 
Importance attached to Conditions of the Tonsil, 955. 
Immunity Against Cholera, 568. 
Importance of the Spleen in production of Immunity 

against Tetanus, 691. 
Important Experiments Toward Maintaining Purity 

of the Milk Supply, 573. 
Improved Middle Bar Powder Blower, 795. 
Improvement of Hearing After the Removal of Polypi 
and Granulations. From the ^ Middle Ear, Louis J 
Lautenbach M. D., M. D. 
Inaugural Address, 678. 
Inoculation of Measles, 955. 

Indication and preferable Methods for Mastoid Opera- 
tions. 791. 
Indications for Administration of Chloralamid, 239. 
For Enucleation of an Eye, 111. 
Technique and Results of Operation on Append- 
ages, 873. 
Inebriety, R. M. Wigginton, M. D., AVaukesha, 

Wis., 311. 
Infantile Eclampsia, 762. 

Influence of Chloroform upon the course of Normal 
Labor as Shown by the Tachadynamometer, 258. 

Of Disease of the Ear upon the Development 

and Course of Insanity, 225. 
Of Habitations in Propagation of Tubercu- 
losis, 284. 
Of Horizontal and Vertical Positions on the 

Cerebral Functions, 736. 
Of Mineral Baths in Normal and Pathological 

Menstruation, 920. 
Of Special Societies and Section work on the 

development of JS'eurology in America, 554. 
Of treatment of Syphilitic Mother during 
Pregnancy on Health of Infant, 662, 764. 
Ingrowing Toe-nail, 662. 

Injections of Glycerine to Induce Premature La- 
bor, 621. 

Of Iodoform in Goitre, 619. 
Injury to Hand— Proposed Operation, 19. 
Insanity Among Convicts, 559. 

Following Surgical Operations, 230. 
Instruments for Appliance of Galvanic Current to the 

Orifice of Eustachean Tube, 735. 
Interesting Cases in Abdominal Surgery, 25. 

Case of Empyema, 426. 
Intestinal Anastomosis, 77. 

Anastomosis by an Improved Method with 

two plates and two knots, 54. 
Resection, 21. 
Intra-peritoneal Ectopic Gestation, 621. 

Pulmonary Injections in Pulmonary Tuber- 
culosis, 427. 
Uterine Asphyxia with Report of three Cases, 
Geo. F. Hulbert, M. D., St. Louis, Mo., 407. 
, Uterine Injections in Puerperal Infections, 376. 

Intravenous Injections of Corrosive Sublimate in Cases 

of Cerebral Syphilis, 466. 
Intubation, 989. 
Intubation for Papilloma of Larynx, 283. 

With Report of Cases, G. D. Nutt, M. D., Williams- 
port, 398. 
Invalid Pensioners as Life Insurance Risks, H.T. Guss, 

Washington, D. C, 640. 
Inversion and Falling of the Puerperal Uterus, 506. 
Iodide of Potash in Headache, 694. 
Iodine Treatment of Goitre. 76. 
Iron Subcutaneously in Chlorosis, 620. 
Irreducible Hernia; Abscess of the Omental 

Stump, 752. 
Irrigation of the Bladder, 758. 
Irritable Conditions of the Stomach, 881, 

Japanese Double-Tailed Fish, 365. 
Justifiable Prevention of Conception, 175. 

Knots in the Umbilical Cord, 622. 

Labia Chancre in Cigar-Makers 883. 

Labor Obstructed by Ovarian Tumors, 494. 

Large Cyst of Kidney; Nephrectomy; Recovery, L. 
S. M'Murtry, M. D., 368. 

Doses of Digitalis in Croupous Pneumonia, 582. 
Doses of Strychnine in the Treatment of Pul- 
monary and Cardiac Diseases, Thomas J. 
Mays, A. M., M. D., 713. 

Lateral Anastomosis by the Murphy Button for Artifi- 
cial Anus, G. D. Thomas, M. D., Chicora, Pa., 396. 

Lawyer'.^ Criticisms of Expert Testimony, 563. 

Leaving Children to the Care of Nurses, 574. 

Lesion of the Right Temporo-Sphenoidal Lobe, 561. 

Limited Importance of Albuminuria in Diagnosis of 
Bright's Disease, 539. 

Local Disinfection, 618. 

Long Continued Fevers in Louisiana, 894, 

Losophan, 229. 

Loss of Hair, 871. 

Ludlum on Physiological and Morbid Relations between 
Uterus and the Eye, 662. 

Malignant Lymphoma, 869. 

Maternity Hospitals and Their Results, Joseph Price, 

A. M., M. D., Philadelphia, 389. 
Measles and Scarlet Fever, 251. 
Measurements of the Liver at Different Ages, 189. 
Mechanical Treatment of Locomotor Ataxia, 661. 
Medical Aspects of Empyema following or Complicating 
Croupous Pneumonia, 61. 

Education in the United States, 610. 
Treatment of Inebriety, T. D. Crothers, 
M. D., 623. 
Membranous Dysmenorrhoea and Uterine Casts, 465. 
Meningocele, 251. 

Menstruation in a Child aged Six, 662. 
Mental Disorders, John Curwen, M. D., Warren, 

Pa., 480. 
Mercurial Ptyalism; Hepatic Abscess, Charles Cary, 
M. D., Buffalo, N. y., 353. 

Treatment of Glanders in the Human Sub- 
ject, 835. 
Method of Bringing Down the Arms After Ver- 
sion, 506. 

Of Localizing Points in the Hemispherical Gan- 
glia, 557. 

Of Treating Compound Fractures, 222. 
Metrical Equivalents, 577. 
Milia, 373. 

Milk Supply of Louisville, 283. 
Miliary Tuberculosis and Gummata occurring in the 

Same Lung, 308. 
Modern Pathology and the Pathology of Nervous Dis- 
~ eases, 917. 
Mono-Bromide of Camphor in Vertigo Epilepsy, 843. 



Morphine and Gastric Secietion, 32. 

Movable Kidney and Some Nervous and Other Symp- 
toms Arising From It, Samuel Ayers, M. D., Pitts- 
burg, 482. 

Multiple Cystomas of the Liver Treated by In- 
cision and Evacution, John B. Roberts, A. M. 
M. D., Philadelphia, 963. 

Multiple Cyst of Ovary, 409. 

Mutual Interest of Medical Profession and Insurance 
Companies in Prolongation of Life, 63. 

Myoma of Uterus, 409. 

Myositis Ossificans, .^82. 

Narcolepsy, 913.'' 

Naso-Aural Diphtheria, With the Report of a Case, 
Laurence Turnbull, M.D,, Ph. G., Philadelphia, 719. 
Nasal Deviations, Dr. George M. Lefferts, 198.- 
National Health Service, 340. 
Nature and Treatment of Angina Pectoris, 918. 
Nayet on Effects of Inoculation in Animals of 
Human Cancer and Cancervous Products, 994. 
New Method of Curing Inveterate Soft Corns between 

the Toes, 1011. 
New Method of Cutting CEsophageal Stricture, 542. 

Method of Direct Fixation of Fragments in Com- 
pound and Un-united Fractures, 464. 
Method for Radical Cure of Varicose 

Veins, 770. 
Method for Treatment for Strictures of the Rec- 
tum, 60. 
Operation for Bad Cleft Palate^ 309. 
Operation for Varicose Veins, 55. 
Reagent for Albumen in Urine, 620. 
Treatment of Hernia, 59. 
Treatment of Hydrocele, 878. 

Obstinate Cough of Pregnancy, 693. 

Olive Oil in Lead Colic, 870. 

One Hundred Radical Operations for Inguinal Hernia 

Performed After The Method (tf Bassini, 567. 
One of Bismarck's Habits, 460. 
On The Increasing Prevalence of Scabies, Henry W. 

Stelwagon, M. D., Philadelphia, 356. 
The Weight of the Brain, 554. 
Opening Mastoid Cells in Acute Inflammatory Middle 

Ear Diseases, 790. 
Operating Accident, 44. 

Operative Hernia at the French Surgical Con- 
gress, 876. 
Operations in the Vertebral Canal, 541. 
Operation for Anterior Cleft Palate in Infants and 
, older Children, 56. 
Operative Procedures for Carcinomatous Tumors of 

The Breast, J. McFadden Gaston, M. D., Atlanta 

Ga., 820. 
Operation for Tumor of Prostate Gland, 754. 

For Stricture of the Ureter in Hydronephrosis 

and Pyonephrosis, 53. 
For Umbilical Hernia in the New born 
Child, 582. 
Osteo-Myelitis, 0. Willington Archebald, M. D., 

Jamestown Md., 401. 
Otacoustic Treatment, 787. 
Ourselves as others see us, S. S. Towler, M. D.,Marien- 

ville. Pa., 675. 
Ovarian Tumor weighing one hundred and eleven 

pounds from a Child of Fifteen, 263. 
Ovariotomy on Patients over Seventy by American 

Operators, Mary Sherwood, M. D., Baltimore 

Md., 50. 

With Pregnancy, 428, 
Over Crowded Population and Public Health, 875. 

Painful Micturition in Women, 146. 
Papilloma of Larynx, 756. 

Paralysis of the Arm Following Application of Es- 
march's Bandage, 730. 

Parasites in India, 828. 

Parathyroid Glands in Man, 179. 

Partial Thyroidectomy, 20, 179. 

Parotiditis Complicated by Orchitis, Prostatitis and 

Hemoptysis, 272. 
Pathogenesis of Hepatic Abscess, 619. 
Pathological Conditions following Piercing of Lobules 
of the Ear, 787. 

Specimens; Incarcerated Testicle; Strangulated 
Hernia, 285-286. 
Pathology and Etiology of Diphiheria, 690. 
Of Laziness, 765. 
Of Nervous Disease, 880. 
Peculiar Case of Appendicitis, 287. 

Symptoms in an Infant Due to Contracted Pre- 
puce, 272. 
Pelvic Inflammation, J. C. Sexton, Rushville, 

Ind., 436. 
Pepsin and the Ferment Lab.; Estimation of the Di- 
gestive Power of Gastric Fluid; Artificial Diges- 
tion, 528. 
Peptonuria in Phosphorus Poisoning, 463. 
Perinephritic Abscess — Ending with Perineal Litho- 
tomy, 262. 
Periproctitis with an Abscess, M. L. Currie, M. D., 

Mt. Vernon, Ga., 203. 
Pes Planus; Cyst of Thyroid; Multiple Uric Acid Cal- 
culi; Sarcoma of Jaw with Suspected Syphilis, Ros- 
well Park, M. D., A. M., Buffalo, N. Y.,' 163. 
Pharmacology in Europe, 379. 
Phenosalyl an Innocuous Antiseptic, 837. 
Phosophorus Poisoning, 946. 
Phonograph in treatment of Deafness, 793. 
Psychical Dislocation and the Theory of Medium ism, 

John B. Purdon, M. D., Cullman, Ala., 467. 
Physiological Action of the Albumoses found in the 
Tissues in Diphtheria, 835. 

And Therapeutic Influence of Testicular Liquid 
on Animal Organism, 808. 
Pilocarpine in Elephantiasis, 349. 
Plaster of Paris in filling Defects in Bone; 448. 
Pneumonectomy, 154. 

Pneumotomy in Abscess of the Lung, 408. 
Points of Similarity, A. L. Benedict, Buffalo, 108. 
Of Similarity, W. L. Martin, Banco 

N. J., 215. 
In the Clinical History of Erysipelas, 61. 
In treatment of Gastric Ulcers, 760. 
Poisoning by Lysol, 867. 
With Turpentine. 
Pomegranate Bark in Dysentery, 870. 
Ptomaine Poisoning, 266- 

'Porro ' for Osteomalacia In the Pregnant, 947. 
Post Operative Sequelae of Pelvic and Abdominal 
Surgery, Joseph Price, A. M., M. D., Philadel- 
phia, 157. 
Poulticing the Ears, 308. 
Precocious Development, 410. 

Pregnancy in a Case of Cured Metro-Salpingitis — the 
Electro Treatment of Metritis with Laceration of 
the Cervix, G. Betton Massey, M. D, Philadel- 
phia, 669. 
Preliminary Report on Disinfection of Clothing 

etc., 879. 
Premature Sexual Development, 968. 
Premature Sexual Development, 427. 
Prepatellar Bursitis, Tumors of the Thyroid, Torti- 
collis and Deformity of Neck due to Vertebral 
Disease, Osteo- sarcoma of Femur, Roswell Park 
A.M., M. D„ 473. 
Present Condition of Otology in Europe, 793. 

Position of Hypodermic Method in Treatment 
of Syphilis, J. Wm. White, M. D., Philadel- 
phia, 124. 
Position of Surgery of the Prostate, 265. * 

Status of Thoracic Surgery, 66. 
Status of Tuberculin, 63. 
President Roberts and Homoeopathy, S. S. Towler 
M. D., Marienville, Pa., 33. 



Prevention of Tuberculosis, 994. 

Prevention of Deaf Mutism, 786. 

Preventive Treatment of Tetanus, 660. 

Primary Perineal Operations, Mordecai Price, M. D., 
Philadelphia, 716. 

Prize of the American Neurological Associa- 
tion, 957. 

Problems of Public Interest Concerning the Insane, 
Orphens Everts, M. D , College Hill, Ohio, 663. 

Progress of Sanitary Knowledge Among the Women of 
England, 682. 

Prophylactic and Therapeutic Value of Food, 685, 

Prostatectomy, 154. 

Pseudo Hermaphrodism, 761, 

Membraneuse Enteritis and its Role in Gyne- 
cology, 644. 

Pulmonary Tuberculosis, 809. 

Purulent Pleurisy Opening in the Lumbar Region, 427. 

Pyelitis of Pregnancy, 144. 

Pyosalpinx Opening into the Rectum, 428. 

Quinsy or Peri-Tonsillar Abscess and Acute Follicular 
Tonsillitis; Their Differential Diagnosis and Treat- 
ment, Dr. George M. LeflFerts, 41. 

Railroad Surgery, W. Murray Weidman, M. D. 
Reading, 44(». ' 

Rapid death from Carbolfc Acid, 881. 
Ravogli (A) on Syphilitic Plaques, 957. 
Recent Developments in Gunnery of Interest to Medi- 
cal Jurists, 60. 
Rectal Injections of Salt Water Solution in Acute 

Anemia, 801. 
Heeurrent Cancer, Talipes, Abscess of Neck, Craniotomy 

Roswell Park, A. M., M. D„ 121. 
Reform Features of the Gothenburg System of Liquor 

Traffic, 766, 
Relation between the Alkalinity of the Blood and 
Intestinal Absorption, fcSl. 

Of t'atellar Tendon Reflex to Ocular Reflexes 
in General Paralysis of the Insane, 918. 
Relative Merit of Present Methods of treating 

Pyelo-nephrosis, 57. 
Remarks on Diabetes, 62. 
Removal of Breast for Tuberculous Condition, 286. 

Of a Lithopoedion Thirty years in the body,385. 
Of Pathogenic Bacteria from Drinking Water 

bv Sand Infiltration, 686. 
Of Seminal Vesicles, 154. 
Removing Odors from the Hands, 651. 
Report of Cases, 1009. 
Jleport of a Case, 755. 

Of Interesting Cases of Abdominal Surgery, 

M. Price, M. D., 15. 
Of the Committee on Leg'slation 106.. 
On Re trict'on and P)evention of Tuber- 
culosis, 678. 
Of Three Months in the Jefferson College Hos- 
pital, W. Joseph Hearn, M. D., Philadelphia 
Pa., 855. 
Researches of Cholera and Vibrioes, 834. 
Resection of a Rib for Empyema followed by 

Lateral Curvature of the Spine, 942. 
Pteview of Ulcerative Endocarditis, 60. 
Ri*^ Resection for Empyen a, 181, 
Riders' Bursa, 463. 
Ringworm of the Fcalp, 882. 

Role of the Posterior Urethra in Chronic Urethri- 
tis, 773. 
Rules for passing the Sound, 700. 

Rumination in Man, and its Relation to the Act of 
Vom ting, 6 4. 

Salicylic Acid as a Taenifuge, 773. 

Acid for Tape-worm, 836. 
Salicylate of Soda per Rectum, 843. 
.Salol as an Intestinal Antiseptic, 341. 

Sarcoma, 252. 

Of Head of Tibia, 286. 
Scopolamine Hydrobromate, 692. 
Second Operation for Carcinoma of Breast, 289. 
Sensativeness of the Peritoneum, 115. 
Sensory Symptoms of Three Syphilitic Cord 

Cases, 561. 
Separation of the Lower Femoral Epiphysis, 621. 
Serum-Therapy and Treatment of Tetanus, 297. 
Sewage Disposal Problem in American Cities, 680. 
Short Articles Preferable in live Medical Journals and 

Medical Societies, 455. 
Shoulder Presentations in Primipara with Case, 

James C. Pearson, M. D., Mitchell, Indiana, 484. 
Sign of Breech Presentation, 838. 
Significance of Vaginal Discharges, 810. 
Simple Meningitis, 754. 


American Medical Association, Section on Neurol- 
ogy and Medical Jurisprudence, 52, 654. 

American Public Health Association with the In- 
ternational Congress of Public Health, 676. 

Clinical Society of Louisville, 206, 251, 281, 372. 

Louisville Medico-Chirurgical Society, 133, 214, 
256, 284, 331,409, 750. 

Philadelphia County Medical Society, 25, 721. 

Philadelphia Academy of Surgery, 975, 1012. 

Section on Orthopaedic Surgery of the College of 
Physicians of Philadelphia, 939. 

Surgical Society of Louisville, 176, 819. 

Orleans Parish Medical Society, 894. 

Western x\ssociation of Obstetricians and Gynecol- 
ogists, 484, 524. 

Sodium Arseniate in the Neuroses, 559. 
Some Considerations of ^the Therapeutics of Diabetes 
Mellitus, Alfred Eichler, M. D., San Francisco, 
Cal., 429. 
Some Draw-backs of Borax in Epilepsy, 349. 

Diseases of Glandular Tissues at the Base of the 

Tongue, so-called Lingual Tonsil, 290. 
Forms of Insanity and Quasi-Insanity in Chil- 
dren, Charles K. Mills, M. D., Philadel- 
phia, 323. 
Medical Phases of the World's Columbian Ex- 
position, A. L. Benedict, A. M., M. D., Buf- 
falo, N. Y., 724. 
Notes and Suggestions on Aseptic and Antiseptic 
Surgery of the Present Time, Franklin Staples, 
M. D., Winona, Minn., 273. 
Practical Post Mortem Points, Henry W. 
Cattell, A. M., M. D., Philadelphia, 711. 
Splenotomy Performed by Monod, 322. 
Spontaneous Amputation of an Inverted Uterus, 543. 
Rupture of the Symphysis Pubis During 
Labor, 385. 
Stackie's Method in Chronic Aural Catarrh, 790. 
Staphylococcus in Osteomyelitis, 540. 
Statistics Concerning Eye Diseases in the Rocky 
Mountain Region, John Chase, M. D., Denver, 
Colorado, 552. 

Of Mammary Carcinoma, 729, 
Stenosis of the OEsophagus, 132. 
Stone in the Bladder with a Report of Cases, Floyde 

Wilcox McRae, M. D., Atlanta, Ga., 379. 
Strabismus, Old Dislocation of Shoulder with Injury of 
Plexus, Prolapsus Recti, Roswell Park, A. M., 
M. D., 241. 
Strychnine in Nervous Vomiting, 799. 

For Snake Bite, 265. 
Study of the Myelin Degeneration of the Pulmonory 

Alveolar Epithelium, 997. 
Study of the Relation of General Disease to the 
Development of Cataract, Edward Jackson, A, 
M.,M.D., 931. 
Study of Aural Syphilis, 793. 

Of Exophthalmic Goitre, 607. 



tSubcutaneous Osteotomy of Neck of Metatarsal 

Bone for Hallux Valgus 939. 
Sabcataneoas lajectioa of Salol in Tuberculosis, 918. 
Successful End to End Suturing of Intestine, 59. 
Suckling and Quinine, 770. 
Sub- Cortical Cyst of the Lower Part of the Ascending 

Parietal Convolution, 557. 
Sugar in Urine of Pregnant, Lying-in and Nursing 

Women, 506. 
*' Suggestion " In the Cure of Disease, J. T. Axtell, 

M. D., Newton, Kas., 545. 
Suggestions on the treatment of Locomotor 

Ataxia, 556. 
Sulphur in Chlorosis, 620. 

Sunstroke with Considerations of treatment, 62. 
Suppuration of Knee-Joint, 943. 

Supra-Pubic Cystotomy, A. C. Strickler, M. D., New 
Blum, Minn., 783. 

Cystotomy for removal of Stones from Blad- 
der, 751. 
Cystotomy with Removal of Three Stones, One 

Encysted, from the Bladder, 413. 
Lithotomy, 156. 
Surgery in the Insane, 558. 
Of ChiMhood, 700. 
Of the Thorax, 426. 
Of Tubal Pregnancy, Joseph Price. A. M., M. D. 

Philadelphia, 507. 
Of the Ureter, 57. 
Surgical Treatment of Cholera, 76. 
Surgery of the Gall-Bladder, 114. 
Surgical Treatment of Gall-stones, 920. 
Suture after Laparotomy, 921. 

Suturing the Tendo-Achillis in the Correcti(jn of De- 
formities of the Feet, H. Augustus Wilson, 
M. D., 366. 

The Ureters, 155. ' 
Syphilis Ignorans, 284. 

Syphilitic Infection, a Vehicle of Communication of 
Tuberculosis, 684. 

Spinal Paralysis, 581. 
Syringomyelia Arthropathies, 419. 

Technical Construction of the Anus Preternatur- 

alis, 346. 
Testes in a Subject otherwise Female, 622. 
Tests of Death, 230. 

Terpene Hydrate in Bronchial Catarrh, 153. 
The Necessity for the Early Regognition and 

Treatment of Suppurative Diseases of the 

Tympanum and their Relation to Cerebral 

Complications, S. MacCuen Smith, M. D. 

Philadelphia, 934. 
The Pyogenic Properties of the Typhoid 

Bacillus, 946. 
The Moral Imbecile, 981. 
Therapeutics of Croupous Pneumonia, 985. 
Tumors of the Peripheal Nerves; With the Reports 

of a Case of Sarcoma of the Sciatic, Thomas .S 

K. Morton, M. D., 969. 
The Action and Safety of Chloroform, 652. 
The Anatomy and Surgical Treatment of Inguinal 

Hernia and its Better Methods for Cure, Henry t). 

Marcy, M. D., L. L. D., Boston, Mass., 639. 
The Bacteriological Craze, 909. 
The Country Doctor, 763, 
The Diagnosis and Nomenclature of Fevers, Nelson G. 

Richmond, M. D., Fredonia, N. Y., 319. 
The Drip Sheet, 111. 
The Earliest Men, 609. 
The Erect Posture for Gynecological Examinations, 

William B. Dewees, A. M., M. D., Salina, Kan- 
sas, 854. 
The Food Exposition, 833. 
The Forms of Diabetes, 348, 773. 
The Great Value of a Close Observation of Other Men's 

Work, W. H. Link, M. D., Petersburg, Indiana, 737, 

The Height of Man, 720. 

The Importance of Early Attention to the Disability 
Caused by Infantile Paralysis, A. B. Judson, 
M. D., 747. 
The Irruption of ''Cranks," 802. 

The Limitations of Therapeutics in the Control of Dis- 
ease, Henry M. Lyman, M. D., Chicago, 592. 
The Morbid Anatomy of Traumatic Anchylosis, 

Thomas H. Manley, M. D., New York, 775. 
The New Chemistry of the Stomach as Means of Diag- 
nosis and Guide to Therapeutics, 65. 
The Palpable and Movable Kidneys, Paul Hilbert, 39. 
The Patent Medicine Business, 395. 
The Path of Improvement in Cancer Treatment, 299, 
Therapeutical Use of Electricity, 559. 
Therapeutic Effect of High Latitude, 762. 
Hints, 692. 

Hints from Foriegn Journals, 799, 835. 
Therareutio Effects 271. 

The Relation of Disease and of Morbid Conditions 
Other than Those Located in the Eye to the Forma- 
tion of Cataract, G. E. De Schweinitz, M. D., 885. 
The Relation of the Ocular Nerves to the Brain, Charles 

Zimmermann, M. D., Milwaukee, 811. 
The Treatment of Acute Pneumonia with Ice and Sup- 
.porting Measures, Thomas J. Mays, A. M , 
M. D., 817. 
The Treatment of Carbuncle by Carbolic Acid Injec- 
tions, C. H. Wilkinson, M.D., Galveston, Texas, 439. 
The Treatment of Diphtheria, R, A. Patterson, M. D., 

Aurelian Springs, N. C, 351. 
The Testicle in Ileeditary Syphilis, 911. 
The value of the Hands and <",f the Fingers, 621. 
Tincture of Iron for Burns 76. 
Tin-Pois'^ning, 770. 

To Disinfect Sewers, Water-closets, etc., 838. 
To Prevent the Svncope of Chloroform, 620. 
Total Extirpation of the Scapula with the Arm Re- 
tained, A.M. Phelps, M. D., 39 i. 
To the Physicansof Pennsylvania, G. H. Tibins, M. 

D , 294, 
Toxic Effects of Gallic Acid, 920. 

Jaundice dueti Infectious Diseases, 70. 
Tracheotomy for Wasp-Sting, 771. 
Transfusion of Nervous Tissue in Neurasthenia, 350. 
Transmission of Tuberculosis to Foetus, 770. 
Traumatic Aneurism, 256, 

A d Artifical Amputation in the L'-wer 

Extremities, 55. 
Aneurism of the Common Femoral Artery, 

with ligature of External Arteries, 59, 
Hernia of the Lung, 427. 
Rupture of Small Intestine, 5 <. 
Treatment of Stricture of the Sigmoid Flexure and of 

the First Portion of the Rectum, 1005. 
Treatment of Fracture of the Leg, J. T. Berghoflf, 

M.D., St. Joseph, Missouri, 928. 
Treatment of Vulvar Vegetations by pure Car- 
bolic Acid, 958.| 
Treatment of Obesity by an Exclusively Nitrogene- 

ous Diet and Copious Libations of Water, 990. 
Treatment of Appendicits, 309. 

Of Burns by Subnitrate of Bismuth, 801. 
Of Cholera, 6V 
Of Diphtheria, 465. 
(>f Eclampsia by Morphine, 801. 
Of Exophthaloiic Goitre, 555. 
Of Hemorrhoids by Electric ty, 349. 
Of Infantile Convulsions, 661. 
Of Insolation, 62. 

Of Large Ovarian Cyst, with report of Case; 
Extirpation of the Coc 'yx for Congenital Cyst, 
Edward P. Davis, M. D.,Phila., 94 
Of Loss of Sexual Power by Ligation of 

Veins, 219. 
Of Malaria by Potassium or Sodium 

Nitrate, 76. 
Of Pulsating Pleurisy and Pneumo- 
thorax, 426. 


Of Scarlet Fever, W. C. Hollopeter, M. D., 

Philadelphia, 327. 
Of Tubercular Disease of Hip Joint, 567. 
Trephining for Subdural Hemorrhagp, 867. 
Trichinosis, F. W. Wilcox, M. D., Minonk, Ills . 248. 
Tropical Diarrhoea, 679. 

Suppurative Hepatitis, 77. 
Tuberculin in Treating Pulmonary Tuber- 
culosis, 946. 
Tuberculosis and the Food Supply, 684. 

Caused by Bites, 309. 
Tubercular Arthritis, 19.* 

Tumors in Left Hypochondriac and Epigastric Re- 
gions, 214. 
Tumors of the Neck, 57. 
Tumor of Mesentery, 253. 
Twisted Umbilical Cord, 206. 
Typhoid Fever, 9U. 

Two Recent Cases of Excision of the Vermiform 
Appendix For Chronic Relapsing Appendicitis 
in the Interval, Thomas G. Morton, M. D., 973. 

Unconscious Delivery, 542, 

Unnecessary Restrictions to Surgery, 53. 

Unusual Case of Triplets, 293. 

Ureterectomy, 59. 

Urine in Myxoedema, 661. 

Urethral Growths, 411. 

Use of Cocaine 194, 7i>ft. 

Use of Milk in Health, H. F. Slifer, North Wales, 
Pa. 195, 

Use of Thiol in Treatment of Burns, 149. 

Use of Cocaine in Small-Pox, 995. 

Uterinr Complicaions, their Trpatment and Mistreat- 
ment, P. C. Palmer, M. D., Kansas, City, Mo., 547. 
Thrombosis following Post-Partum Hemorrhage 
and its Relation to Puerperal Infection, R. 
W. Reynolds Wilson, Philadelphia, 50. 

Vaginitis from Bestiality, 155. 

Valvular Lesions of heart. Pulmonary Oedema, 
Oligochromaemia, Simple Anaemia, Charles G. Stock- 
ton, M. D., 87. 

Vafelinein Certain AfFetion of Middle Ea'-, 956. 
Variation in Typt in General Paralysis, 309. 
Varicose Ulcers, 25-'. 
Vaseline as a Lubricator, 404. 

Vaseline in Certain Affections of theMddle Ear, 348, 
Vehicle for Iodide of Potash, 322. 

Venesection in Acute Rheumaiism Involving the 
Gravid Uterus, E. M. Furey, M. D., Norristown, 


Vocal Physiology and Systematic Voice Training for 
the Prevention of Disease of the Larynx, J. Walter 
Park, M. D., Harrisburg, 597. 

Volvulus, F. Byron Robinson, M. D., Chicago 
Ills., 959. 

Vomiting of Anesthesia, 810. 

Vulvo-Vaginal Tumor, 22. 

Water Filtration and Cholera, 643. 

Water Supply of Chicago Sources and Fanitary As- 
pects, 685. 
Weight of the two Sidf s of the Brain, 103. 
What Benefit can Ear Patients derive from Nasal 

What are the Indications for Rem' val of the Uterine 

Appendages, Marie J. Mergler, M. D., Chicago, 

111., 117. 
What is the Value of Salicylates in Rheumatism, ?>4kZ. 
What Operations May we perform on the Gall 

Bladder? 53. 
What should Constitute Res fonsibility in the Medical 

Sense in Insanity, 560. 
When and Why Baby should have a Drink of 

Water, 224. 
When Cataract is ready for Operative Treatment, 531. 
Whooping Cough in an Infant Eighteen Days Old, 

John M. Currier, Newport", Verm nt,363'. 
Why Electricity S< metimes JFails to Control Uterine 

Hemorrhage, Augustin Goelet, M. D., 246. 
Williams on Papillomatous Tumors of Ovaries, 921. 

Yellow Fever in the Mexican Republic, 687. 

Vol. LXIX, No. I. 
Whole No. 1896. 

JULY 1, 1893 

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No. 1896. 


Vol. LXIX— No. 1 




JOHN PUNTON, M. D.,* Kansas City, Mo. 

By virtue of his mysterious and com- 
plex nature man has attracted the atten- 
tion of the brightest intellects of every 
department of learning from time imme- 
morial, and this attraction is even greater 
to-day than ever before. 

To the searcher after truth he has ever 
proven himself an enigma. Considered 
from whatever standpoint, man has fur- 
nished more riddles and problems to the 
square inch than any other creature we 
know anything about; certainly no other 
object has been the subject of more severe 
and critical analysis than he, yet to-day 
we are all willing to admit the fact that 
there is still much concerning man that 
is still unknown to us. 

While this may all be true, nevertheless 
it is a very gratifying fact for us to know 
that each and every century has furnished 
a greater or less number of investigators 
in the various departments of -medicine, 
whose combined labors have solved many 
of the more difficult problems concerning 
his physical nature, and rendered possible 
the study of man on a scientific basis. 

In an impartial investigation, therefore, 
sound method requires that we take into 
consideration all the phenomena pre- 
sented, each in its completeness and 
natural relations, and an estimate of their 

•-Professor of Nervous and Mental Diseases, Univer- 
sity Medical College, Kansas City, Missouri,- Special 
Lecturer Western Dental College; Neurologist to All 
Saints Hospital, etc. 

full value given in accordance with their 
relative weight and bearing on the prob- 
lems at issue. By the application of such 
methods in the study and order of nature, 
we soon discover the elements of a plan or 
system which shows progress in the un- 
folding of its parts from the lower and 
more simple forms of life to the higher 
and more complex. Each department of 
nature is thus seen to become higher and 
higher through the addition to itself of 
something in organization and endowment 
which the next below it does not seem to 
manifest or possess, but which have def- 
initely been demonstrated to reach the 
very height of its power and perfection in 
the human brain convolutions. 

In no other department of medicine is 
this law of evolution more beautifully il- 
lustrated or carefully observed than that 
which has been found to exist in the de- 
velopment of the central nervous system. 

The very fineness of architecture and 
delicacy of structure has rendered its study 
beyond human skill until quite a recent 
period, hence the true nature of its anat- 
omy and physiology all along the ages has 
been very imperfectly understood. The 
force and gravity of this lack of knowl- 
edge is very apparent when we remember 
that one of the fundamental principles of 
medicine declares that to understand 
pathological we must first possess a thor- 
ough knowledge of physiological pro- 


Original Articles. 

Vol. Ixix 

The history of the progress of medicine 
also shows that just in proportion to our 
knowledge of the anatomy and physiology 
of any given part, does our knowledge of 
the symptomatology of its disease advance. 
The great aim, therefore, of scientific in- 
vestigation, as Dr. Starr says, is to asso- 
ciate symptoms with lesions, and this has 
been done to a remarkable degree of late, 
chiefly along the lines of anatomy and 
physiology, through the instrumentality 
of the microscope. 

In tracing the general outline of the 
history of the progress of medical science, 
it seems to me that it naturally divides 
itself into two great epochs, the first dat- 
ing as far back as the days of Vesalius, 
the worthy founder of anatomical science 
in the year 1514, A. D., and the second 
from the introduction of the microscope 
into medicine by Leuwenhoeck, until the 
present time. 

These two great epochs stand out in 
special salience and present a marked con- 
trast in the steepness of the rise of knowl- 
edge they present when duly compared. 

In addition to this, they also represent 
the two great departments of study which 
have furnished all that is known concern- 
ing man's physical nature. These may 
be termed: I. microscopical; II. mi- 
croscopical study. In these are included 
all the varied lines of scientific research ; 
and all the various discoveries, from what- 
ever source, belong to one or the other of 
these periods. 

In this connection it must be remem- 
bered that the student of medicine has 
necessarily been forced to depend upon 
the different means and methods placed at 
his disposal by the arts and sciences of his 
own epoch, hence the smallest technical 
discovery frequently became of inestimable 
value. Considering the crude and limited 
means and methods of investigation be- 
longing to the first epoch, the labors of 
such men as Vesalius, Eustachius, Fallo- 
pius, Pachioni, Harvey, Willis, Vieussens, 
Meckel, Scarpa, and many others whose 
names are immortalized in anatomical 
nomenclature, cannot be over-estimated 
and their discoveries testify as to their 
greatness and earnestness of purpose. 
Nevertheless it is the microscopical epoch to 
which our greatest advance belongs, and it is 
this we are compelled to recognize as fur- 
nishing the most marvellous and brilliant 
results, as well as the most practical 

knowledge. It is to certain consequences 
therefore, concerning this microscopical 
period and notably those of the past few 
years, that I desire to call attention at 
this time, consequences that seem to me 
to be of the utmost importance to the gen- 
eral practitioner, as well as to the neurolo- 
gist in their daily practice. 

The marvellous extent of the changes 
wrought cannot be realized by all the 
members of our profession, and for obvious 
reasons. Those of you who studied medi- 
cine before the change took place have 
been unable to follow the new develop- 
ment of knowledge on account of the 
exigencies of general practice with its ever 
increasing demand on your time and ener- 
gies, for the successive steps have followed 
each other with a rapidity almost bewil- 
dering. Then again the large number of 
practitioners who studied medicine more 
recently and during the time in which 
these changes were in actual progress, but 
were yet subject to doubt, necessar- 
ily learned fragments of the new but large 
quantities of the old doctrines concerning 
the genesis of nervous diseases, thus ac- 
quiring a mixture which to-day we know 
to be quite incompatible and consequently 

Before our present perfected knowledge, 
the pathology of nervous diseases was us- 
ually inferred from analogy, but to-day we 
know that the analogy was false and the 
malady itself quite different from that 
which was then supposed to exist. The 
vast increase of our knowledge of the 
anatomy and physiology of the nervous 
system, which is so salient a feature of re- 
cent progress, and the application of this 
to disease, has been found to be most use- 
ful in the correction of such erroneous in- 
ference and the displacement of the work 
of fancy by ascertained positive fact. 

By it also our nomenclature has been 
greatly enlarged, our classification of dis- 
eases wonderfully improved and modified 
and our means and methods of diagnosis 
thereby rendered more perfect and relia- 

The application of the perfected micro- 
scope to pathology immediately increased 
the range of so-called organic diseases. The 
term organic being used to designate those 
diseases in which the lesion is visible and, 
as visibility is only a relative term depend- 
ing on the means of vision, it is easy to 
understand the great changes which have 

July 1, 1893. 

Original Articles. 

been wrought in this department alone. 
For instance, prior to the discovery of 
Tnrck ('^ That a break in the conductiv- 
ity of certain nerve fibres in the spinal 
cord always led to a degenerative process 
which spread upwards or downwards ac- 
cording to its seat ") our knowledge of 
the -pathology of spinal diseases was very 
imperfect, hence a correct diagnosis was 
impossible ; but the application of this fact 
and its further elaboration furnished us 
with that most valuable pathological 
classification of diseases of the spinal cord 
into systemic and non-systemic diseases. 

In view of all the remarkable advances 
which have been made of late in this de- 
partment of medicine, is it any wonder 
that those only familiar with the old, 
should be lost in the mazes of the new ? 
All important,, therefore, is the knowledge 
which recent investigation affords concern- 
ing cerebro- spinal architecture and its use 
as a factor in the diagnosis of nervous 

The wonderful perfection which has 
been attained of late in elucidating the 
complex mechanism of the nervous system 
may be said to largely depend upon three 
methods of research, viz., I. The degen- 
erative method discovered by Turck, in 
1850; II. The atrophic method of Von 
Gradden, in 1870; III. The developmental 
method of Flechsig, in 1877. 

It was the further elaboration of these 
that gave us the present perfected knowl- 
edge of cerebro- spinal architecture, and 
rendered it most valuable as an aid in 
diagnosis. In their utilization, the most 
remarkable results have been accomplished, 
and still in process of enlargement. 

It would be impossible for me to give in 
detail the structure and functions of all 
the various parts which constitute cerebro- 
spinal architecture, so that at best I can 
give but a hurried glance of some of the 
more important, yet I will endeavor to 
review briefly some of the principal facts 
as demonstrated by the more modern 
researches in America, England, France 
and Germany, and those which are now 
generally conceded and accepted as 

The department of medicine that relates 
to neurology is based on physiological 
principles, and recognizes the nervous sys- 
tem, with its various appendages and cor- 
relating energies, to be the supreme con- 
trolling force in man. Its functions taken 

collectively, associate the different parts of 
the body in such a manner that a stimulus 
applied to one organ excites to action 
another. It is composed of a series 
of connected central organs called 
collectively: I. the cerebro-spinal centre, 
or axis; II. ganglia; III. nerves; IV. 
certain modifications of the peripheral 
terminations of nerves which form the 
organs of the external senses. 

It is divided into two great systems, 
I. Cerebro- Spinal; II. Sympathetic. 

The first includes the brain, spinal cord, 
cranial nerves, spinal nerves, and is in 
direct connection with the cerebral centers. 

The sympathetic is not in direct con- 
nection with the cerebral centers, but is so 
indirectly, by means of numerous branches 
which go to and come from it. It essen- 
tially consists of a double chain of gang- 

The spinal cord is a long rod or mass of 
nervous tissue, enclosed in a bony canal 
formed by the bones of the spine. It con- 
sists of white and gray nervous tissue, the 
white being most external and capable of 
division into various tracts or columns, 
which are connected centrally with the 
brain. It gives off at regular intervals the 
spinal nerves in successive series, which 
are distributed to the various muscles. 

The white substance is made up of at 
least nine tracts of fibres which differ in 
function according to its situation. It 
is usually divided into three primary col- 
umns, viz: {a) anterior; {h) lateral, and 
(c) posterior, {a) The anterior is motor 
in function; {!)) the lateral column is 
much more complicated and has a mixed 
function containing both motor and sen- 
sory fibres. 

(e) The posterior columns of the cord 
present two well defined tracts known as 
the column of Goll and column of Bur- 
dach, and these are said to be essentially 
sensory in function. Now the study of 
the course and distribution of these differ- 
ent tracts and their special uses constitute 
one of the most difficult problems in 
neurology, for it is by these that impres- 
sions from without are conveyed to the 
brain and transformed into other impulses. 
One of them is said to convey the sen- 
sations of pain, another those of touch, a 
third varying degrees of temperature, 
a fourth that of muscular sense; 
while still others represent the so-called 
motor tract, which for the most part 

Original Articles. 

Vol. Ixix 

crosses at the mednlla, while certain fibres, 
known as the column of Turck, ascend to 
the brain on the same side. 

The gray matter of the spinal cord is 
made up of several distinct groups of cells 
which are said to be the residence of 
special centers which govern different 
functions of the body, the principal ones 
being that of reflex action, trophic and 
nutritive powers, as well as the source of 
innervation of the sympathetic system. 

As the gross anatomical features of the 
brain are already familiar to you, I shall 
merely refer to them incidentally, but 
speak more especially of these parts the 
knowledge of which, in my judgment, is 
more requisite in the diagnosis of nervous 

The brain consists of a variety of nerve 
centers arranged in layers or masses, con- 
nected with each other as well as the 
spinal cord and other organs by means of 
various tracts of nerve fibres which differ 
in function and structure. The most 
external layer consists of gray matter 
and constitutes the cerebral cortex. 

JSTow the cortex of the brain is the seat 
of all conscious mental action. It is 
therefore the receptacle of all impressions 
made upon the organs of sight, hearing, 
touch, taste and smell. Here and here 
only do such impressions become trans- 
formed into conscious appreciation of ex- 
ternal objects. From it also proceed all 
the motor fibres distributed to the volun- 
tary muscles, under the name of the motor 
tract, as well as the sensory fibres which 
gives rise to psychical perception of ex- 
ternal impressions. 

Now certain portions or areas of this 
cerebral cortex preside over different dis- 
tinct functions or actions of the body; in- 
deed it may truly be said that every part 
of the body is represented in it. As Dr. 
Eamsey well says: '•' By facts at our com- 
mand to-day we know that one portion is 
limited to vital processes, hence its de- 
struction causes instant death;" another 
part presides over the various movements 
of the body, hence paralysis of motion re- 
sults from injuries to this area; a third 
enables us to appreciate the sense of 
touch, another of pain, another of temper- 
ature, and disturbances of these functions 
will be apparent when these regions are dis- 
eased. Another portion presides over the 
sense of sight, hence disturbances of vision, 
or even blindness, may follow injury or dis- 

ease of this part. In the same manner hear- 
ing and smelling are governed, and when a 
combined action of all these parts are de- 
manded, as in the exercise of reason, will, 
or self control, the knowledge gained by 
these means can be contrasted, and their 
specific functions correlated in such a 
manner as to meet the exigency of the case. " 

From this, then, we learn that the ex- 
ternal surface of the brain can be mapped 
out into a series of definite areas or 
regions, and say positively that this or that 
one controls or presides over this or that 
particular function of the body. By a 
thorough knowledge of these special areas, 
the skilled physician can determine by the 
symptoms which their derangement pro- 
duces, the exact situation, extent and 
nature of the lesion. 

So positive, gentlemen, is the informa- 
tion thus afforded to-day, that surgical 
operations are now performed daily for 
their relief, whereas a few years ago such 
a proceeding was considered impossible. 

I will now endeavor to demonstrate the 
various areas or. regions referred to, to- 
gether with their special functions. For 
convenience I have divided the brain into 
four parts, or lobes, viz. : I. Frontal ; II. 
Parietal; III. Occipital; IV. Temporal. 
The names, as you will observe, corres- 
pond to the names of the bones of the 
skull which encase them. They are sep- 
arated from each other by three important 
fissures, viz.: I. Sylvius; II. Eolando; 
III. Parieto-Occipito. 


The first frontal lobe represents four 
principal convolutions which are separated 
by fissures, the largest one being termed 
the precentral, and divides this region 
into two parts, an anterior and posterior. 

That part which lies in front consists of 
three convolutions, first, second and third 
frontal; it is sometimea termed the pre- 
frontal lobe. In these are supposed to re- 
side the centers which control the higher 
mental faculties such as judgement, 
reason, will, self-control, etc. Any injury 
to this part is liable to cause a disturbance 
of these faculties. At the lower portion 
of the third frontal reside the centers 
which Broca long ago designated as the 
speech area, or the seat of language. 
Injury or destruction of this may cause an 
impairment of speech, or even complete 

July 1, 1893. 

Original Articles. 

The posterior portion of the frontal lobe 
constitutes a part of the motor area, and 
is known as the ascending frontal. 


This lobe is also made up of four princi- 
pal convolutions named, Ascending Parie- 
tal, Superior Parietal, Supra-Marginal, 
and Angular. These are separated from 
each other by small fissures, and divided 
into two portions by a larger fissure termed 
the fissure of Eolando. This is the im- 
portant landmark for all surgical opera- 
tions in and around the motor area. 

That portion situated in front of the 
fissure, together with the ascending frontal 
and a portion of the superior parietal 
termed the Paracentral lobule, constitutes 
the whole of the motor area. In this re- 
sides all the centers which govern the vol- 
untary movements of the body. For con- 
venience it may be divided into three parts : 
An {a) upper, {h) middle, {c) lower. The 
first governs the movements of the legs ; 
the middle, the arms; the lower, the lips 
and tongue. Any injury to these may 
cause corresponding paralysis to the parts 
supplied. The remaining portion of the 
parietal lobe not specially belonging to the 
motor area, and separated from it poste- 
riorily by a large fissure termed the intra- 
parietal, represents the regions which are 
probably the seat of conscious perceptions 
of touch, pain and temperature, and con- 
sequently may be styled a sensory area. 


The occipital lobe is made up of three 
convolutions which preside over the sense 
of sight, and the recognition of familiar ob- 
jects by the eyes depends entirely upon 
the integrity and activity of the cells of 
this portion of the brain. Any injury to 
this may cause disturbance of vision and 
destruction of the cuneus may produce 



Finally, the temporal lobe is the region 
or seat of the centers which enable us to 
consciously appreciate sounds, odors or 
taste, hence it represents the centers of 
the special senses of hearing, smelling and 
taste. Like the occipital, it is composed 
of three convolutions separated from each 
other by small fissures. 

All these various centers are thus seen 
to have their residence in the cerebral cor- 

tex. This cortex forms a vault or dome 
arching the large mass of white substance 
beneath and known technically as the cen- 
trum ovale. 

Proceeding in every direction from 
these centers are the nerve fibres which 
converge from all parts of the cortex to 
form the corona radiata and centrum 
ovale. Starr says that these fibres may be 
arranged in three sets, viz. : I. Association 
fibres which connect the cells of different 
areas in the same hemisphere. 

II. Oommisural fibres which connect 
homologous parts of the opposite hemis- 
pheres and therefore cross the median 

III. The projection or peduncular 
fibres which connect the different areas of 
the cortex with other parts of the nervous 
system lying below it. They converge 
from all parts of the cortex and gathering 
together at the upper level of the basal 
ganglia either terminate in the optic thal- 
amus or pass between the basal ganglia to 
other parts of the brain and spinal cord. 
The fibres terminating in the optic thala- 
mus constitute the visual and auditory 
tracts, while the rest of the fibres pass on 
at once to the internal capsule where they 
form a series of different tracts with 
special functions. From before back- 
wards they are as follows : 

I. The speech tract, conveying speech 
impulses to the pons and medulla. 

II. The face tract, conveying facial 
motor impulses to the pons where the nu- 
cleus of the seventh nerve resides. 

III. The arm tract, destined to the arm 
center in the cord. 

IV. The leg tract, transmitting leg im- 
pulses to the leg centers in the cord. 

V. The fibres conveying impulses to 
the muscles of the trunk. 

Hence, it appears that the centers for 
the legs, which are highest in the cortex, 
become lowest in the capsule, while the 
face fibres, which are lowest in the cortex, 
become highest in the capsule; but the 
arm fibres are situated between the two at 
the cortex as well as the capsule. 

These various tracts of fibres constitute 
the motor tract whose course through the 
anterior two- thirds of the posterior por- 
tion of the internal capsule is probably 
familiar to all of you, and from this point 
passing to form the middle third of the 
crus cerebri or pes peduncle, thence to the 
pons where the facial fibres decussate to 

Original Articles. 

Vol. Ixix 

opposite sides to end in their respective 
nuclei, while the balance of the fibres are 
continued by way of the pyramids of the 
medulla, where they for the most part 
decussate to form the crossed pyramidal 
tract of the cord while a few are continued 
down the cord, on the same side as far as 
the mid-dorsal region^ under the name of 
the column of Turck. All of these fibres 
which are continued from the brain to the 
spinal cord terminate in the large cells 
found in the anterior cornua of the gray 
matter where they again take origin to be 
distributed to the voluntary muscles of the 
body. Besides the motor set of projec- 
tion fibres there is still another set known 
as the sensory tract. It lies just posterior 
to the motor tract and passes inwards into 
the parietal convolutions to the capsule, 
where, in general terms, it may be said to 
take a similar course to that of the motor. 
It is made up of fibres which convey the 
sensations of touch, pain, temperature and 
muscular sense; hence any lesion in any 
part of its course causes corresponding dis- 
turbances of those functions. 

Thus the fibres which constitute the in- 
ternal capsule possess, as Dr. Eanney 
says, greater interest than many others, 
both from a physiological as well an anat- 
omical standpoint. 

Late researches have shown that it con- 
tains a successive series of tracts or bun- 
dles, the functions of some of which are 
definitely known while others are not yet 
well determined. Taken collectively they 
may be arranged as follows : 

1. That part of the internal capsule 
designated as the caudo lenticular portion, 
which lies anterior to the knee, is com- 
posed of fibres whose functions are imper- 
fectly understood. They seem, however, 
to pass chiefly to the cortex of the frontal 
lobes and thus they would appear to be as- 
sociated with the higher mental faculties. 

2 The functions of the majority of the 
tracts of fibres, however, found in the thal- 
amus and lenticular portion of the internal 
capsule are definitely known and serve as 
valuable clinical guides to the localization 
of cerebral lesions which directly involve 
or create pressure upon them. They are 
as follows : 

A. In the region of the knee are found 
the motor fibres of the face. These facial 
tract fibres decussate to opposite sides in 
the middle of the pons variolii terminating 
iji their nuclei. 

B. Posterior to this we have the 
pyramidal motor tract or the will tract of 
Spitzka, those destined for the arm centers 
in the cord lying anterior to those destined 
for the leg. These control the voluntary 
muscles or movements of the limbs. 

C. Posterior to this we have the sensory 
tract which convey sensations of all kinds 
from the peripheral organs to the cells of 
the cerebral cortex where they can be ap- 
preciated by consciousness. 

D. Next in order is the speech tract, 
whose fibres allow of communication be- 
tween the speech area of the cortex and 
nuclei of origin of the facial, glosso- 
pharyngeal, pneumogastric, spinal acces- 
sory and hypoglossal cranial nerves. 

This center is also connected by associa- 
tion fibres with the centers of hearing, 
viz: the first temporal convolution, and 
those of sight, viz.: the occipital convo- 
lutions. Thus the cortical center of co- 
ordinated speech movements is capable of 
receiving excitation from the center of 
hearing when replies to spoken language 
are demanded, and from the centers of 
sight when written or printed language 
calls for a verbal reply. It is also put in 
communication, as we have already seen, 
with the nerves which preside over the 
apparatus of speech. 

JEJ. The optic fibres pass through the 
extreme posterior part of the capsule. 
These are designed to join the optic 
nerves with the convolutions of the oc- 
cipital lobes. This constitutes the visual 

F. Another tract in the capsule is the 
hypo-glossal tract. This is an independent 
tract of fibres which connects the cortical 
centers for the movemen»ts of the tongue 
with the nucleus of origin to the twelfth 
cranial nerve within the medulla. It 
therefore probably joins the lower third of 
the pre- central or ascending frontal con- 
volution with this nerve. It is supposed 
to pass through the internal capsule near 
its knee, and anterior to the motor fibres 
which govern the limbs. Lesions of this 
tract would produce symptoms allied to 
those of Duchennes disease, viz. : Bulbar, 
or glosso-labio-pharyngeal paralysis. 

G. The course of the fibres associated 
with the rest of the special senses, viz. : 
those of taste and smell, are not yet so 
well understood as in the case with the 
eye and ear. This latter, or auditory tract. 

July 1, 1893. 


probably passes through the lower and 
posterior part of the internal capsule to its 
respective centers in the temporo-Sphe- 
noidal lobe. 

From the course of the various 
cerebral tracts, we learn that any lesion 
which lies in the centrum ovalle at any 
point posterior to the pre-central suclus of 
the frontal lobe must necessarily either 
effect the motor, sensory, visual or auditory 
tracts, or individual fibres of these, and the 
symptoms of their derangement will neces- 
sarily correspond to the parts affected. 
Bearing also in mind the following rule of 
lesions confined to the motor area that the 
nearer the lesion is to the cortex the more 
liable will only one center be affected; 
hence monoplegic paralysis usually results. 
While the nearer the lesion is to the cap- 
sule the more liable two or more tracts are 
to be affected ; hence hemiplegic paralysis 
together with hemiansesthesia usually oc- 

The importance of this knowledge can- 
not be over estimated, as by this we are 
enabled to decide upon the possibility of 

relief by surgical interference, as well as 
to define the special nature and seat of the 
lesion. While it must be confessed that 
the study is very tedious and compli- 
cated, yet the conclusions to be reached 
are of the highest importance to the 
patient as well as physician. 

As the'var iou s facts embodied in this paper 
are scattered at intervals throughout the 
wide domain of medical literature and 
therefore not easy of access to all, I have 
endeavored to collect and present them in 
as tangible a form as possible, trusting 
they may prove of service to any who may 
be called upon to treat the more obscure 
diseases of the brain and spinal cord. I 
might also add that in the preparation of 
this paper I have made free use of the 
opinions and statements of such authors 
as Spitzka, Ferrier, Hughlings Jackson, 
Horsley, Gowers, Charcot, Nothnagle, 
Edinger, Ranney, Luys, Flechsig, Gray, 
Sachs, Starr, and Dana, as well as many 
others, besides the cullings from the 
numerous periodicals devoted exclusively 
to neurological science. 



K. S. HOWLETT, M.D., Bigbyville, Tenn. 

In these, the closing years of the Nine- 
teenth Century, scientific research is being 
carried on with a zeal and an enthusiasm 
unknown to any other age. Men are be- 
coming more unselfish and self-sacrificing 
n their pursuit of knowledge, are giving 
their time and their fortunes and devoting 
their very lives to the attainment thereof. 
In every science, the devotees are carrying 
their investigations deeper and deeper, 
and the wonderful scientific mysteries un- 
folding in response to their endeavors 
only seem to whet the appetite and in- 
crease the unsatiable desire for further 
knowledge. As a result of this untiring 
work, wonderful progress is being made 
in every science and, the best of it all is, 
this knowledge obtained is being used for 
the elevation, the advancement and the 
comfort of the human race. 

^Presidential Address, delivered before the Maury 
•County, Tenn., Medical Society. 

In this movemxcnt, the scienee of medi- 
cine does not lag behind. In no other 
field is there greater display of earnestness, 
zeal, pluck and determination and in none 
other are there more brilliant and at the 
same time more practically beneficial re- 
sults. In no other profession, without 
any exception, has there been manifested 
more modesty, unselfishness and self-sac- 
rifice, more of that greatest of all virtues, 
charity, or love of fellowman, and in none 
other has there been more ardent, disin- 
terested work done or more heroism shown 
in attempting to relieve suffering human- 
ity and no other more deserves the admir- 
ation and the gratitude of the whole world. 

Every true physician must feel an 
added heart beat of pride in his profession 
when he contemplates these things. 

That branch of medical investigation 
which has been given the most attention, 
which has already made the greatest 



Vol. Ixix 

change in onr therapeutics and which bids 
fair to well-nigh revolutionize our ideas 
about many diseases and their treatment, 
is the study of bacteriology. A few years 
ago it was given only a passing thought 
and spoken of (if spoken of at all) only 
indifferently or contemptuously; but to- 
day these little parasites are taking quite 
a prominent position in the medical world. 
The most distinguished investigators are 
fairly living among them, cultivating 
them, studying their nature, their appear- 
ance, their habits, their products and the 
effect of themselves and their products 
when intro'luced into the system; the 
most progressive medical schools are add- 
ing special laboratories for the study of 
them, medical lectures and essays are re- 
plete with them and the medical journals 
are full of them. Now, the outside world 
is catching on and the newspapers are 
giving space to them and even the patent 
medicine advertiser has a knowledge of 
their existence and is trying to turn them 
to a profit by promises of a complete, sure 
and universal destruction to them. 

These innumerable little pests float in 
the air we breathe, in the water we drink, 
live in the food we eat, hide themselves in 
the carpets, on the walls, and in every 
crack, nook and corner of the houses in 
which w^e live, and so great is their tenac- 
ity to life that they live on for months 
and years, resisting heat and cold and al- 
most every effort we make for their de- 
struction, even daring sometimes to take 
up their abode with impunity in some of 
our boasted disinfectants and multiply 
and develop there. 

They are continually and persistently 
seeking an entrance into the body that 
they may find a congenial soil and set up 
their destructive process there. Having 
once forced their unwelcome en- 
trance into the body and found a suitable 
place upon which to plant their batteries 
and establish their head-quarters, they put 
their chemical laboratory to work and 
manufacture poisoned ammunition with 
which to carry on effectively their fierce 
assault upon every vital fortress. They 
send these destructive products into the 
brain, the heart, the digestive organs and 
each shows the disturbing effects of their 
presence and each trembles, weakens and 
well-nigh succumbs to the unwonted inva- 

But nature does not tamely submit to 

this intrusion upon her domain and the 
bacteria do not find an unmolested march 
or an unresisting or easily conquered in- 
habitant. For within the body are found 
living cells, or phagocytes, which stand 
ever on guard, keeping up a close and 
ceaseless vigil, ever ready and waiting to 
rush to the rescue and repel the advance 
of any destructive army. Hence, we 
have an uncompromising warfare between 
cells and parasites, between native inhabi- 
tants and foreign invaders. As the 
bacteria exert their destructive influence 
chiefly through the agency of chemical 
poisons, so likewise the living cells use 
their counteracting poisons as a means to 
destroy them and render inert their 
products. This contest is one that knows 
no truce. Each side carries the black 
flag and it is a war of extermination and 
so fierce do the combatants become that 
the conquerors even devour the dead 
bodies of their adversaries. 

While this savage interchange of hostili- 
ties is going on and this furious battle 
raging, all is noise, strife and confusion 
within the system. But when the victory 
(as, fortuately, it usually does), perches 
upon the banner of the living cell, and 
the smoke of battle has cleared away, we 
find that every evidence of the ferocious 
contest has been removed and all is peace, 
quiet, order and regularity. Once more, 
not only this, but the industrious little 
cells often go further and so fortify the 
system that forever thereafter they can 
easily protect themselves from the future 
assaults of these same bacteria and give 
the body an immunity from them. 

So nobly, so brilliantly and effectively 
do these little cells do their part, and so- 
many valuable lessons have they taught 
the close and wondering observer, that the 
admiring physician looking on feels like 
bowing in humble respect before them and 
deems it an honor to be an ally to such 
courageous heroes and a coveted privilege 
to be a disciple of such judicious teachers. 

This so-called doctrine of Phagocytosis 
is an interesting and fascinating one, and 
while many will call it only a beautiful 
theory, it has already added something to 
our therapeutic resources and promises 
much more for the future. 

But while the study of bacteriology has 
added much to our knowledge of 
the etiology and pathology of dis- 
eases and has aided us materially in 

July 1, 1893. 



the rational treatment thereof^ perhaps 
the greatest benefit we have derived from 
it and the greatest advancement that has 
been made is in that art which is the per- 
fection of all medical skill, viz. : the pre- 
vention of disease. Knowing these little 
germs to be the cause of so many of the 
ills which flesh is heir to, there is nothing 
more natural than that the greatest effort 
should be made to prevent their entrance 
into the body. 

Now, the first thing we notice in study- 
ing bacteria, is that dirt and filth are the 
most congenial soil for their propagation 
and development; hence that most impor- 
tant of all hygienic laws, always appre- 
ciated, but now that we understand the 
habits of these parasites, more so than 
ever before, that cleanliness is absolutely 
essential to health and that filth is the 
most prolific cause of disease. The cities 
and larger towns have long since learned, 
by sad experience, the fatal results of 
neglecting this, as well as other hygienic 
laws, and have conformed their laws and 
customs accordingly. They locate and 
build their houses with due regard to 
drainage, ventilation, sewerage, etc., so 
that they can have pure, fresh air to 
breathe; they arrange their water- works 
so that they can have good, clean water to 
drink; have boards of inspectors to see 
that they have wholesome food to eat, and 
most important of all, they give their 
boards of health power to compel every 
man to clean up his premises, disinfect 
privy vaults and cess-pools, and to see that 
nothing is allowed to be carried on or to 
remain on one's premises which would be 
a nuisance or source of danger to the 
health of his neighbors. The result of 
this is that we have cleaner cities, with 
better health reports and a constantly de- 
creasing rate of mortality and an almost 
complete suppression of the former fatal 
and dreaded epidemics. Where so many 
people are crowded together, the neces- 
sity for such precautions forces itself upon 
the attention of people and in pure self- 
defense they must not neglect them. 

But, while this improvement has been 
going on in the cities, what has been done in 
the smaller towns and country? Nature 
is exceedingly kind to the country inhabi- 
tants. She furnishes them with fresher 
air and purer water, if not polluted by 
man himself, than the cities can obtain 
with all their improved appliances, and 

the people have become so accustomed to 
think of the country as the place for city 
people to go for health, and they have 
neglected the best known laws of hygiene 
for so long, with comparatively few bad 
results, that they never think of such 
things until sickness and death comes and 
they begin to look around for a cause 
thereof. I wish to direct your attention 
for a very few moments to some of the 
very noticeable conditions frequently 
found in reference to country hygiene. 
First, we will notice the water supply. 
Sometimes we find several members of a 
family stricken with a fever, generally ty- 
phoid, at the same time, and, in looking 
for a cause, we will investigate the water 
supply of such a family. We will gener- 
ally find an old well, which probably has 
not been cleaned oat for years, located in 
the lowest part of the premises, so that all 
the filth about the yard and (perhaps) lot 
must necessarily drain right into it. Or, 
you will find a spring down in the stock 
lot, with horses, cattle, hogs and geese 
running all around it and the spring 
branch choked up with grass or leaves. I 
recall one of this kind. In the family of 
the owner of the place I had five cases of 
typhoid fever following each other in 
quick succession, and in the house of a 
tenant, who used water out of it, I had 
three or four cases, while among the 
pupils of a school, who got their water at 
the same place, I had several cases of both 
typhoid and malarial fevers. Of course, 
my attention was immediately directed to 
this spring. I found it located about 
thirty yards from the house, at the foot of 
a little hill, upon which was situated the 
residence with all the out-houses (a con- 
dition often found), the branch from it 
choked up with half-decaying weeds and 
grass, so that the stream could only make 
its way sluggishly and laboriously away. 
And, just above this spring, I found a 
large hog- wallow, separated from the 
spring by a mound apparently thrown up 
for the purpose, about twenty feet through, 
and a muddy, slimmy stream from this 
flowed right down by the fountain of 
the spring and emptied itself into the 
branch just a few feet below. It was not 
only not surprising that they had typhoid 
and malarial fevers as results, but a won- 
der that they did not have the whole cata- 
logue of diseases besides. This is prob- 
ably an extreme case, but if we will ex- 



Vol. Ixix 

amine the wells and springs from which 
the majority of even the well -to-do people 
get water, we will find that that water 
must certainly be far from being pure and 
could be wonderfully improved by just a 
little ditching, a little more attention and 
by showing a little better judgment in 
locating the buildings^ stock-lots, etc., 
with reference to the source of water sup- 
ply. I wish to put especial stress upon 
this point, for I believe it is most sadly 
neglected in the country and a most pro- 
lific source of sickness, suffering and even 

Now,when we come to notice the houses 
in which the people live, according to my 
observation, very little fault can be found 
with the dwellings of the well-to-do which 
have been built lately. They usually 
select healthy locations for them, and the 
rooms are generally large and well ventil- 
ated. One error that ought to be con- 
demned is that not uncommon one of 
having cellars under the houses, which are 
used for storing potatoes or other vegeta- 
bles in, or for milk houses, and many of 
which get very damp, having water stand- 
ing in them at times, and which it is not 
possible to properly clean out. Going to 
the rooms of the upper story, another 
improvement that might be suggested is 
that they be given more height, as they are 
generally used for sleeping rooms. We 
ought also to alwaj^s protest against the 
common practice of the whole family 
sleeping in one room. When we come to 
look at the outhouses, we frequently find 
the stables and privy in uncomfortable 
proximity to the dwelling house, and one 
very grievous error is the almost universal 
neglect of using disinfectants of any kind 
about the joremises. Where people live 
some distance apart, the necessity for this 
is not felt, but disinfectants are cheap 
and many cases of sickness might be pre- 
vented by their systematic use. 

But when we visit the houses of the 
great mass of tenants upon the farms in 
our country, we find everything to con- 
demn. They are frequently located close 
to a branch or creek, in the lowest, wettest 
place about the whole farm. Almost all 
of them are built of logs, generally old 
rotten logs which have already served out 
their term of usefulness in other houses. 
These furnish an inviting lodging place 
for every species of germ. The floors of 
these cabins are laid right on, or very 

close to, the ground ; the sleepers, if there 
are any, have usually decayed from the 
constant damp, and the floor is sunken 
and uneven. The celling is so low that 
one can scarcely stand erect in the room. 
The doorway is low and narrow, and usu- 
ally (but not always) we will find a little 
square hole left in the wall somewhere, 
which serves to let in light and air in 
the stead of a window. 

But it is not necessary for me to con- 
tinue the description of these houses, for 
they are so common all over this country, 
being found upon the farms of our most 
prosperous farmers, that every physician is 
perfectly familiar with them and will agree 
with me that the picture is not overdrawn. 
In this so-called house, consisting of one 
room, with perhaps a covered pen behind 
it for cooking purposes, must live a whole 
family^ oftentimes doing their cooking, 
eating and sleeping all in the same room, 
and if any are sick they must remain in 
the room where this is carried on. As the 
great majority of these tenants are negroes, 
who are certainly not noted for neatness, 
you will readily see what the condition of 
affairs is and imagine what the results 
will be. Such seeds sown will inevitably 
bring forth a harvest of disease and death. 
Now by sickness the owner of the farm 
frequently loses the labor of his hired 
man or tenant for days and weeks when 
such service can illy be spared, or by 
death loses him altogether, and it seems 
to me that not only for humanity^s sake, 
but as a pure matter of business and as 
a paying investment, they should set fire 
to; or tear down, these old death traps and 
build for their tenants larger, more healthy 
and more comfortable houses. 

There are many other means by which 
the simplest laws of health are most fla- 
grantly violated throughout the country 
that might be mentioned with interest, 
especially in reference to school houses 
and other public buildings, but they are 
patent to every observing physician and 
every one duly appreciates the evil thereof. 

The question that presents itself to us 
is, what can be done to mitigate such 
evils ? The inhabitants of this free coun- 
try are a liberty-loving people, and every 
man feels that even if he has a condition 
of affairs upon his premises which brings 
sickness to his family or tenants, but does 
not harm his neighbor, it is nobody's busi- 
ness but his; he quickly resents any in- 

July 1, 1893. 



terference in the matter, and it is useless 
to try to make and enforce laws to compel 
him to change these things. But the 
greater number of our farmers are intelli- 
gent, reasonable people, and they would 
very willingly keep their premises in bet- 
ter hygienic condition if their attention 
was only directed to the evil of neglecting 
to do so. But how little attention has 
been paid to this, even by the physician 
himself. We see statistical reports from 
the cities, showing the death-rate and the 
number of infectious diseases, and we see 
the causes of these diseases discussed 
often and persistently in the medical and 
daily papers, and we see articles from the 
health officer, making a demand upon 
the people to attend to the removal of all 
conditions favorable to the dissemination 
of disease. But country people seldom 
ever think of these things at all in con- 
nection with their homes. Now wouldn't 
it be an interesting thing to country phy- 
sicians if we could get at like statistics 

concerning the country neighborhoods ? 
And could'nt we, by a little work, make 
the report of the county health officers 
less vague and more valuable ? Suppose 
we appoint a statistician, and let each 
physician report to him the number of 
deaths, of infectious diseases, calling es- 
pecial attention to those that are due to 
improper hygienic surroundings. Let the 
statistician tabulate and arrange these 
reports, publish them with appropriate 
remarks each month, and call the atten- 
tion of the people to the preventable 
causes of disease, and urge them to clean 
up their premises, look after their springs, 
disinfect privies, etc., just as city health 
officers do from time to time. It would 
certainly be a wonderful improvement 
upon the present manner in which in- 
definite reports come to the health offi- 
cer, from which he makes his report, 
and would add much to the accuracy, 
interest and true value of such report,, 
both to the physician and the people. 


JOSEPH PRICE, A.M., M.D., Philadelhhia, Pa. 

The mooted questions in surgery grow 
less as our experiences enlarge and ripen. 
There are in our science and art some cer- 
tainties, some points upon which there is 
unanimity of enlightened opinion. There 
are, however, also, as in all other sciences 
and arts, as in all other lines of human 
enterprise and endeavor, disputed points; 
disputed, we must take it, from the stand- 
point of conscientious opinion. These 
differences are the chief factors, the motor 
forces of our advances. Without them, 
inertia would take the place of our activi- 
ties. The fact of our advances is not 
disputed ; the lines along which they have 
been made, direct the way of interesting 
and instructive study. We have a pro- 
found interest in the names and work of 
those toiling pioneers who have blazed the 
trees for our guidance to lessen the diffi- 
culties of our following. What they have 
done for womankind will always lie beyond 
the power of biographical pen to narrate. 
We would find it difficult to distribute our 

* Read before the Philadelphia County Medical 
Society, April 12th, 1893. 

debt of obligation when we come to con^ 
sider the great labors, the brilliant work 
of McDowell, Kimball, and the Atlees, of 
Pean, Keith, Koeberle, Hegar, Billroth, 
Kaltenbach, Kleeberg, Schroeder, Lawson 
Tait, Bantock, Thornton, and others. We 
find stimulus in such names and such 
records for worthy following. They have 
given us the sublime lessons of their 
experience. What masters they are — all 
of them! They represent the genius of 
science, of practical skill; they have en- 
• larged our resources; they have helped us 
to make many lives worth living. Some 
of these men are living to-day, are yet 
giants at the wheels, yet students in the 
solution of great surgical problems. 

In considering the definitions of 
hysterectomy we must bear in mind 
nomenclature. Schroeder's term, myo- 
motomy, is not synonymous with hysterec- 
tomy; is not hysterectomy; it more ap- 
propriately applies to simple extirpation 
of the tumor. Hysterectomy is the re- 
moval (Kimball^'s operation) of the whole 
body, or any section of the uterus, with. 



Vol. Mx 

tumors inseparable therefrom. Such high 
authority as Thornton places within its 
field all cases in which the uterine cavity 
is laid open and more or less of its wall 
removed along with the fibroid; whether 
one or both ovaries are also removed is a 
matter of no consequence. Sometimes it 
is more convenient to remove one or both, 
applying the term vaginal hysterectomy to 
cases in which fibroids, the uterus, and 
the uterine appendages are all removed. 

The progress made in perfecting the 
operation has taken some disputed points 
out of the field. Experience has given 
something of definiteness to our views; 
still there are two camps. The disputed 
points involve methods, rather than 
questions, of the justifiability or safety of 
the operation; on these points there is 
unanimity of sentiment among experienced 
surgeons. There maybe yet some division 
of opinion as to what cases should be 
operated on, and what cases should be let 
alone. The operation was long regarded 
as one of the most fatal in surgery. The 
low rate to which the mortality following 
the operation has been reduced, where the 
cases fall into experienced and skilful 
hands, has given it an abiding and im- 
portant place among the life-saving pro- 
cedures. In the matter of methods, men 
are likely to credit those methods with 
being best which, by their own tests and 
in their own individual and professional 
experience, have given the best results. 
One or more failures with any one par- 
ticular method of procedure drives some 
men to try others. With their first suc- 
cess they christen the baby *'My method," 
" My modification," " My improvement," 
or " My invention," and the entire pro- 
fession is exceedingly glad that a new 
genius has been born into the profession — 
that there is a new light in Israel. 

The history of the treatment of the 
pedicle in ovariotomy has influenced all of 
the older ovariotomists to try the same 
methods and materials to perfect an intra- 
peritoneal method in hysterectomy. The 
early efforts of Schroeder were quite suc- 
cessful. Some of the younger operators 
have improved the statistics by clean ex- 
tirpation, but we yet remain in two camps 
as to the management of the pedicle. 

Operators clinging to the no3ud and the 
extra-peritoneal method are making the 
best showing, operating right along with 
a very low mortality. It cannot be in- 

ferred from the success of the intra-peri- 
toneal method in ovariotomy that im- 
proved or equally successful results will be 
attainable by the intra-peritoneal method 
in supra-vaginal hysterectomy. The re- 
sults in many large and ripe experiences 
establish the fallacy of this idea; such in- 
ference is in blind disregard of essentially 
different conditions. Ligatures cannot be 
safely used in uterine, fibroid, or myoma- 
tous tissue. Silk, as applied to the ped- 
icle in cystomas, is harmless and safe. 

1 would say here that the earlier errors 
in diagnosis, mistaking cystiform degener- 
ation, fibroids, or oedematous myomas, for 
ovarian cystoma were common, and the 
cases were either abandoned or incomplete 
operations done with disastrous results. 
Some of the most skilful operators did not 
escape making these errors. 

The treatment of the pedicle has been 
repeatedly and exhaustively discussed. 
Eesults have dampened the enthusiasm of 
the advocates of the intra-peritoneal 

It is necessary in the removal of about all 
fibroids to make a pedicle. Its manufac- 
ture in extra-peritoneal hysterectomy is 
the one important feature of the opera- 
tion. It should be made small. Suturing 
securely against hemorrhage is also the 
important feature in the intra-peritoneal, 
and the avoidance of hemorrhage and the 
ureters are the important features in the 
extirpation method. 

Shock is minimized in the extra-perito- 
neal method, the operation being shorter, 
exposure and manipulation less, than in 
any of the intra-peritoneal methods. 

The method of turning the pedicle into 
the vagina is a tedious operation; the 
risks of hemorrhage and of injury to the 
ureters is even greater than that of a clean 
extirpation of the cervix. 

The question is often asked, '*Why 
leave the cervix or stump in at all ; it is 
the most common source of hemorrhage 
and sepsis in all the intra-peritoneal 
methods?" Its removal is the perfected 
operation, but the results as yet have not 
been as good as in the extra-peritoneal 
method of treating the stump. 

Hemorrhage is incident to the supra- 
vaginal, as it is to all the methods. The 
bleeding varies greatly, and sometimes is 
absent altogether. In this procedure the 
elastic ligature (Kleeberg's) and the wire 
ligature minimize the risks of hemorrhage. 

July 1, 1893. 



The cliief danger in the intra-peritoneal 
method is bleeding from the pedicle. 
Drainage, or the dry treatment, where ad- 
hesions have been extensive, is of vital 
importance in these operations. It is an 
important object to get and keep the 
stump dry. In some cases you need not 
change the dressings for a week or more. 
They should be changed when they be- 
come moist. The advantage should be 
kept in mind of sewing the edges of the 
peritoneum across the stump, thus preven- 
ting retraction when the loop has become 
somewhat loose from the shrinkage of 
tissue. The duration of the operation is 
one of the many factors to be considered. 
There should be that rapidity consistent 
with due caution and scrupulous attention 
to essentials. There is no time for fussi- 
ness. There is the shock of the anaes- 
thetic. Extensive adhesions, bowel and 
bladder complications^ require painstak- 
ing surgery^ and tedious and slow the 
steps of the procedure, and somewhat 
lengthy, however deft and educated the 
hands engaged. Temperature is an im- 
portant consideration. Supplying dry 
heat throughout the operation will avoid, 
to a very great extent, the shock due to 
the chill of the atmosphere. In the mat- 
ter of shock, long exposure and long 
annesthesia count for much. It should be 
kept in mind^ however, that to deal with 
an abdominal wound carelessly or too hur- 
riedly is bad surgery. Every step should 
be timed to the needs of the case, every 
motion those of a master workman, and 
there should be summoned into service 
every resource of our science and art. 

When we come to consider hysterectomy 
in all its phases, the condition of the pa- 
tients when they come into our hands, tlie 
dire extremity that drives them to us, that 
they come to us with general health broken 
down, often complete physical wrecks, and 
familiar as we are with resultant issues — 
we have no difficulty in appreciating the 
difficulties we have to encounter. The 
professional responsibility is a heavy one. 
The patient's condition suggests the 
urgent question : ^' What should be done ?" 

We appreciate the truth of J. Knows- 
ley Thornton's statements, we accept them 
in the main as surgical truths, into the 
acceptance and practice of which the pro- 
fession should be educated. As to the 
relative value of two very diffierent surgi- 
cal procedures for the cure of fibroid en- 

largements of the uterus, he says: " I feel 
that I am confronting one of the most 
difficult questions in abdominal surgery 
armed with imperfect weapons. Medicine 
has long and vainly endeavored to deal 
satisfactorily with this disease, and now 
the surgeon's aid is invoked. I do not 
deny that many cases have been relieved 
by medical treatment, and that some have 
been cured while under such treatmeut. 
I do think, however, that it is an open 
question how many of the cases cured 
while under treatment were cured by the 
treatment, and I believe the majority of 
such cases have been due to the co-inci- 
dent interposition of Dame Nature. 

"A very large number of patients 
never suffer pain, or even inconvenience 
enough to make them consult either phy- 
sician or surgeon. But admitting all 
this, there undoubtedly remain a large 
number of cases urgently demanding sur- 
gical aid. Some patients are brought face 
to face with death from hemorrhage, ex- 
cessive growth of the morbid elements, or 
constant interference with rest from pain 
and discomfort. Others are gradually but 
surely reduced in strength, and have les- 
ions of vital organs as the result of con- 
stant pressure and displacement. When 
surgical treatment is spoken of, we are 
told that we have no right to interfere 
with fibroids as we do with ovarian tumors, 
because the latter surely kill if left alone 
and the former do not. I am certain that 
this argument is only partly true, and 
everyone who sees a large number of cases 
will bear me out in the statement that 
numbers of women die every year from 
the direct and indirect effects of fibroid 
enlargements of the uterus. 

"I would ask. How much of the gen- 
eral surgery of the day which is dangerous 
to life would continne if surgeons ceased 
to perform operations of expedience, that 
is, to operate for deformities and diseases 
which do not endanger life in themselves, 
though they deprive their victims of all 
the pleasures of life? I affirm, then, that 
there are many cases of fibroid enlarge- 
ment of the uterus which endanger the 
lives of their bearers, and that there are 
many more which make these poor suffer- 
ing women so miserable and useless that 
they are justified in running the risks of 
operation, and that the surgeon is justified 
in operating. We must remember that 
these operations are usually undertaken 



Vol. Ixix 

in extreme cases, and when the patients 
are worn out with disease and suffering. 

" The operation of complete supra- 
vaginal hysterectomy, with removal of 
both ovaries, has become, when properly 
performed, one of the most successful of 
the great operations. 

" Hegar and Kaltenbach, by their new 
extra-peritoneal method, have saved eleven 
cases out of twelve, and the surgeons at 
the Samaritan Hospital have in the last 
year had equally successful results, also 
by the extra-peritoneal method, using 
Koeberle's wire serre-noeud in much the 
same way that Hegar uses the elastic liga- 
ture. These operations of hysterectomy 
and complete supra- vaginal hysterectomy 
still remain, however, very formidable 
operations. They are terrible mutila- 
tions ; ■ the patients are slow in convales- 
cence. Is there then no operation of less 
danger, of quicker convalescence, and of 
better and more perfect results which we, 
as surgeons, can recommend to our pa- 

"Thanks to American surgery, the 
brilliant conception of Blundell, in 1823, 
was made a recognized surgical procedure 

by Battey, in 1874, and from the labors 
of Hegar, Trenholm, Tait, Savage, and 
others, I am able to present to you a per- 
fected operation, which will render this 
formidable hysterectomy still less often 
necessary in the future than it has been in 
the past. 

'^The complete removal of the uterine 
appendages, when efficiently performed, 
cures fibroids of the uterus with rapidity 
and certainty. And I will ask you to re- 
member that this operation is not such a 
serious mutilation, and does not leave be- 
hind it any mark except a small linear 
scar on the perfectly closed abdominal 
parietes. The removal of the uterine ap- 
pendages is attended with infinitely less 
danger to life than are the various opera- 
tions for the removal of uterine fibroids. 

'•'Are we then justified in subjecting 
our patients to the formidable operation 
of supra-vaginal hysterectomy when we 
can cure them by removal of the uterine 
appendages ?^' 

It should be accepted as a settled fact 
that we are never justified in doing a hys- 
terectomy when the appendages can be re- 
moved early in the growth of the tumor. 


F. P. BUTLER, M. D., Marshalltown, Iowa. 

July 3rd, '92, was called to see Mr. P. 
V. J., aet. 73; was informed by the messen- 
ger that he had diabetes, and was requested 
to be prepared to make an examination of 
the urine at the bedside. 20 years ago, 
he noticed that he had to get up once, and 
some nights 2 or 3 times to urinate; has 
always been a strong man living on a farm 
all his life; had never used liquor of any 
kind; in December, '91, his wife died, the 
blow was a very severe one to him, he not 
allowing the family to mention her name 
in his presence. In February, while asking 
the blessing he would sudienly stop, get 
up from the table, rush bareheaded out 
of doors, remain for some time, return and 
probably pick up a paper and read awhile, 
then go about his work; this proceedure 
was liable to be repeated at any meal. At 
this time there was a noted increase in the 
flow of urine; he consulted a physician 
who told him it did not amount to much 

and would soon pass away. He took a trip 
East and returned in a few weeks much 
improved ; this was in April. His son who 
was in the West, desired him to meet him 
in Salt Lake City in May. He made all 
arrangements to do so, when he received 
a letter from his son, telling him that he 
could not be at Salt Lake by May first but 
would be soon. The son, being detained, 
kept writing that he would go soon, when, 
10 days before I saw him, he wrote telling 
his father he would have to put off his trip 
for a long time. This affected the old man 
greatly, and at once there was a noted ia- 
crease in the fiow of urine ; his head pain- 
ed him very much and it was almost im- 
possible for him to sleep, in fact it brought 
on an acute attack of his (I think) chronic 
trouble. He received one injury to the head 
in youth, it was slight and lasted him for 
a short time only; he has never had but 
one sick spell, that was typhoid fever years 

July 1, 1893. 



ago, from which he recovered completely; 
his habits have always been active and 
steady ; he has taken excellent care of him- 

At my visit, I found him very much ex- 
hausted, with neuralgic pains through the 
head and extending to the back and hips; 
he had for nine days been passing an ordin- 
ary chamber full (110 oz.) of urine in 
twelve hours. I applied Fehling's test 
but the result was negative. I prescribed 
F. E. Ergot m. 12, once in four hours, to 
be alternated with 8 grains of phenactine. 
Securing a sample of urine I repaired to 
my office and made a more thorough test, 
and found no sugar and a sp. gr. of 1000. 
His mouth was dry and he, of course, was 
very thirsty, drinking about as much water 
and other fluids as were eliminated by the 
kidneys ; bowels constipated ; relieved by 
pil. cascara sagrada gr. 2. 

July 4th, a sample of urine was brought 
me in the morning ; the color was better ; 
the sample of the day previous being the 
color of water, no sugar, sp. gr. 1002, the 
amount passed being one third less than 
that of the twelve hours previous; he had a 
very comfortable day, appetite fairly good, 
for the past two weeks it has been very 
poor; the evening sample of urine being 
being the same as that of the morning. 

July 5th,rested about the same; passing 
the same amount of urine as on the third, 
increased the ergot to thirty drops, con- 
tinued the phenacetine, appetite not im- 
proved, still very thirsty, slept better than 
he has for several nights ; in the evening 
increased the ergot to one teaspoonful 
t. i. d. 

July 6, Dr. L. saw him in consulta- 
tion; confirmed my diagnosis; patient 
much the same as yesterday, possibly a 
little more exhausted ; his appetite being 

so poor we gave extract beef, also brom. 
potass., grs. 10 in place of the phe- 
nacetine, urine same as yesterday. July 7, 
rested well last night; urine darker color; 
sp. gr. 1002, slight decrease in the 
amount; took more nourishment than us- 
ual, strength about the same; continued 
treatment. P. M., amount urine passed 
in eleven hours 124 oz., sp. gr. 1001; in- 
creased bromides to 15 gr. July 8, A. M. 
Some stronger to-day, ate a hearty break- 
fast, slept well during the night, mouth 
was less dry; from 6.45 P. M. to 7 A. M. 
he passed 114 oz. of urine, 10 oz. less 
than during the preceeding 10 hours ; con- 
tinued treatment with orders to nourish 
him as much as possible; headache better; 
from 7 A. M to 7 P. M., July 8, passed 
135 oz. of urine, but seemed no worse for 
it, sp. gr. 1001. July 9, from 7 P. M., 
July 8, to 7 A. M. July 9, amount of 
urine passed 90 oz., less than he has pass- 
ed since he was taken sick, sp. gr. 1005, 
the highest I have found it; slept very 
well all night, ate a hearty breakfast, 
bowls moved by enema, mouth less dry. 

He gradually grew worse from this time 
up to the 23d ; several times we thought 
he could last but a few hours longer ; the 
morning of the 23d, his long-looked- for 
son arrived and he at once commenced to 
improve, and by the 3d of August he 
needed no medical care, and in a week or 
two left for the west, where he regained 
his original health. • 

This I think a case of diabetes insipi- 
dus, brought on by mental trouble in the 
loss of his wife, and by the great disap- 
pointment in not meeting his son as he 
had expected, and very much desired to 
do; it is purely nervous, because there is 
not a trace of his trouble that will show 
that it was brought on by anything else. 



Dr. Henry Leaman has kindly consent- 
ed to allow me to report this case of me- 
chanical obstruction of the bowel, as it is 
one of great importance, and it is his re- 
port I give and not mine. You will remem- 
ber a similar case reported for the same 
trouble nearly two years ago, and as that 
case was one that many thought strongly 

reported I thought best to call your atten- 
tion to this one reported by Dr. R. Lea- 
man and operated by Dr. Henry Leaman, 
and I had the pleasure of assisting in the 

Dr. Leamai^-'s Report. — I was called 
to see Thomas P. on November 1, 1892, 
who presented the following conditions, 



Vol. Ixix 

yiz. : retention of urine relieved by tlie 
catheter, no passage from the bowels for 
three weeks previous, when he had done 
heavy lifting and active work. My idea 
was that there must be invagination or 
twisting of the bowel, and treated him 
after the usual methods both by mouth 
and rectum, still nothing in way of relief 
was accomplished ; the enlarged adbomen 
grew until the tympanitic condition gave 
place to a slightly dull note everywhere 
over the abdomen on percussion from ex- 
cessive distention. 

The vomiting, which was always present, 
now became somewhat stercoraceous. Re- 
spiration became shallow, rapid, and feeble 
from the encroachment of the diaphragm. 
Pulse feeble, mind wandering. But with 
all this the temperature never rose above 
100°. On November 10, 1892, I called 
in my brother. Dr. Henry Leaman, in 
consultation. It was at once decided that 
nothing but an operation would give the 
patient any chance. Dr. M. Price was 
asked to see the patient and assist in the 
operation. All abdominal pain had ceased 
about three days. 

The operation was done in a little room 
in Carleton Street, and, as usual to the 
location, the envirouments were not of 
the best. The patient was taken from 
the bed and placed on a table and a 
median incision made as in abdominal 
operations; the bowel enormously dis- 
tended«with liquid. A search was made 
for the point of obstruction, but I could 
not find any. Dr. Price also made an 
effort to find the obstruction. Failing to 
find one, we decided to open the bowel 
and empty out its contents and then make 
a thorough search for the obstruction. 
This also failed. The bowel was carefully 
stitched and the patient put to bed. In the 
next forty-eight hours he had about thirty 
evacuations. The bladder had to be re- 
lieved with a catheter. He made an un- 
interrupted recovery. 

Mr. K., patient of Dr. Romaine, of 
Lambertville, N. J., aged thirty-two 
years, had had a number of recurring at- 
tacks of severe pain in the region of the 
appendix, all of which, save the last, 
have yielded in two or three days to pur- 
gation by salines. Last attack occurred 
May 2, 1893, and he was at once freely 
purged. This gave considerable relief; 
bat the pain would return in twelve or 
fourteen hours in as much severity as 

ever. It was decided to have an opera- 
tion, and I was asked to operate. 

May 7. I carefully examined the patient, 
and from th& history and the existence of 
peritonitis, and the fact that all his pain 
and suffering came from the region of the 
appendix, also that he had had a number 
of attacks with the same symptoms, I did 
a section and found from three to four 
feet of ileum adherent in mass over the 
head of the colon, greatly adherent and 
covered with inflammatory lymph. There 
was some pus in the mass, but very little. 
The bowels were completely separated, 
washed and replaced, and then the appen- 
dix looked for and found in a hard mass 
curled up and adherent to the head of 
the colon on one side and to the pelvic 
bone on the other. The adhesion to the 
pelvis was loosened, the appendix and 
bowel were brought out, but the bowel 
could not be removed without great injury. 
So, with thorough irrigation of the peri- 
toneal cavity, stitching of the lower end 
of the wound, the hardened mass at the 
head of the colon, with the appendix at- 
tached, was placed directly under the 
upper edge of the wound and over it a 
gauze drain, which was left in place for 
thirty-six hours; afterward dressed daily. ' 

Patient had no increase of temperature 
or pulse after operation, and made an un- 
interrupted recovery. 

Mrs. H., aged forty years, suffering 
from great nervous prostration, constant 
pelvic pain for the last two years. She 
was treated by Dr. Peltz, her family phsi- 
cian, with great patience and care, but 
without any lasting benefit. 

I examined her in February in consulta- 
tion with Dr. Peltz, and found no mark- 
ed pelvic disease — -nothing that warranted 
an operation. In one week after my visit 
she was examined by a Philadelphia gyne- 
cologist who used an instrument to mea- 
sure the depth of the womb, and its free- 
dom from adhesions. The instrument 
gave her violent pain and greatly increas- 
ed her suffering. May 4th. I again exa- 
mined her and found the uterus fixed, and 
on the left side a large fluctuating mass 
— right side adherent. May 6, 1893. I 
did a section and removed a large ovary 
tand tube distended with blood-clot, con- 
tents measuring about half a pint of decom- 
posing blood and pus ; the right side a pus 

How much this trouble was due to a 

Julv 1, 1893. 



previous existing disease, or how much to 
the intra-uterine examination, I leave you 
to judge. 

Herbert H., son of Dr. H., of Pember- 
ton, N. J. Appendicitis. Operation; 
drainage ; recovery. This is the third case 
in eight months that I have seen in the 
hands of this physician — two operated on 
and recovered. The third, a young man 
nineteen years old. When I was called he 

insisted he was much better, and would 
not submit to operation. He had well- 
marked symptoms of abscess of the ap- 
pendix. He continued to improve, and 
for three months afterward declared to Dr. 
H. that he was perfectly well. While un- 
loading a can of milk he felt something 
give way in the right inguinal region and 
died in twelve hours, before anything 
could be done for him, of peritonitis. 


B. H. POTTS, M.D., Philadelphia, Pa. 

I wish to call attention to a few cases 
of gangrene of the foot and leg that 
occurred during the service of Dr. Willard 
in the Pennsylvania Hospital, and mention 
one case particularly that shows the effici- 
ency of the high operation performed as 
early as possible. 


Man, aet. 42 years. Had always been 
a healthy man. Two weeks before ad- 
mission to the hospital he J^oticed a pain 
in the outer side of the left foot and that 
the little toe of the same foot was black. 
No history of traumatism of any kind 
could be obtained. The pain gradually 
grew worse, and one week after admission 
the nail of the little toe was extracted. 
Sharp and lucinating pams now began to 
shoot from the toes to the ankle. Two 
days later the gangrenous portion of the 
toe was removed, and a laudanum poultice 
applied. At the end of another week the 
entire toe was removed. About this time 
the glands of the left groin became en- 
larged; ung. hydrarg. was applied and 
under this treatment they gradually im- 
proved. The wound of the toe healed at 
the end of ten days, and one week later 
patient was discharged cured. 


Patient was admitted to the hospital in 
1883. Twenty years before this his left 
leg broke out with ulcers on the inner 
side of the tibia, which discharged until 
six months before admission, when they 

healed leaving cicatrices ; about this time 
his right foot began to trouble him. At 
this time also, six months before admission, 
his right foot was frost-bitten, and 
steadily grew worse. The outer side of 
the great toe became sore and painful, 
and this condition extended to the inner 
side of the foot. On admission the great 
toe was gangrenous throughout its extent; 
there was considerable sloughing at the 
end, and its nail had come off; the second 
toe had also lost its nail and both were 
cold and insensible. Vessels were tense 
and thickened, but not atheromatous; 
glands in the right groin were much en- 
larged. The slough gradually extended 
along the inner side of the foot, leaving 
the metatarsal bone of the great toe bare 
and necrosed. The muscles on the sole 
of the foot had sloughed to within two 
inches of the inner malleolus. This 
slough was gray ashen in color, had a very 
offensive odor and was painless. 

The foot was dressed daily with boro- 
glyceride for one week when a charcoal 
poultice was applied. One by one the 
toes were removed, until at the end of 
five weeks all the toes of the right foot 
were gone. The granulations now became 
purple and livid ; there was no soreness or 
pain. Inflammation of an erysipelatous 
character set in, and the general condition 
became very poor. Patient was given tr. 
ferri. elisor, and quinia. The gangrenous 
process slowly advanced until the slough 
extended to the ankle. The patient began 
to steadily lose flesh and strength and died 
from exhaustion at the end of seven 



Vol. Ixix 



Man, 86 1. forty-four years. While ex- 
posed one cold day patient's feet wer^ 
frozen, the left one more severely than 
the right. During the six months follow- 
ing the exposure, but little attention seems 
to have been paid to the feet, but the pro- 
cess of gangrene started and steadily ad- 
vanced and at the end of that time, the 
line of separation having formed, the toes 
of the left foot were amputated. On the 
day following the operation, gangrene of 
the stumps ensued and when patient was 
brought to the hospital, one week after 
the operation, the gangrenous process had 
extended to the knee on the anterior part 
of the leg and a few inches below the knee 
posteriorly. Inflammation extended half 
way up the thigh which was greatly 
swollen and crepitant. Patient was very 
weak ; arteries were atheromatous. 

It was decided to wait until patient's 
condition improved and he was put on a 
course of tonics and stimulants. The leg 
was dressed with a hot solution of bichlo- 
ride 1-1000 and wrapped in cotton and 
wax paper. The line of demarcation 
formed at the end of ten days. Patient's 
condition was improving slowly but stead- 
ily. Two weeks after admission, a small 
black spot appeared on the great toe of 
the right foot which was very painful, 
but did not spread. Four weeks after ad- 
mission, the gangrenous portion of the left 
leg was taken ofE at the knee joint; the 
tissues were all dead and there was no 
hemorrhage; no sutures were introduced 
but the flaps were strapped. The end of 
the femur was black and showed no line of 

Three days later the patella was dis- 
sected away from the soft tissues and the 
periosteum from the bone and the latter 
sawed off about one inch and a-half above 
the condyles. The great toe of the right 
foot was amputated, but at once began to 

At the end of two months the leg stump 
had entirely healed, but the stump of the 
toe was discharging profusely. Until this 
time the patient had seemed to improve, 
but now the gangrenous process began to 
extend from the toe to the ankle, involv- 
ing the whole foot, the inflammation ex- 
tending to the knee. Appetite became 
poor and strength began to fail and pa- 

tient went down steadily until the end of 
the third month when he died from ex- 


Man, ast. fifty-three years. Sixteen 
years ago a piece of ice fell on the right 
foot crushing the fourth toe; this wound 
was carefully treated but was very slow in 
healing and caused him much pain subse- 
quently. Eight months previous to ad- 
mission, in the spring of 1892, a horse 
trod on the right foot and two months 
later another horse trod on the same foot. 
After this last injury the fourth toe of the 
right foot bursted and the whole foot 
looked unhealthy, esj)ecially the toes, look- 
ing blue and feeling cold ; blisters formed 
in different places at different times. In 
the latter part of July, 1892, the fourth 
toe was amputated; the stump healed 
very slowly. During August all the toes 
began to show decided signs of gangrene 
and the pain increased in severity. 

On admission, January 7th, 1893, the 
remaining four toes were found to be gan- 
grenous and the entire lower half of the 
foot was swollen, tender and caused severe 
pain. The urine was free from sugar and 
albumen. Vessels were atheromatous. 
An immediate high operation was advised. 

January 20th, 1893, the leg was ampu- 
tated at the knee joint. No Esmarch 
bandage or tourniquet was used, but digi- 
tal compression was made upon the 
femoral artery in Scarpa's triangle, and 
the vessels caught up as they were cut. 
The popliteal artery was tied, very loosely, 
with a broad ligature composed of four 
strands of No. D catgut. No antiseptic 
solution of any kind was used in the 
wound, but a very dry stump was obtained 
and closed up with catgut drainage. 

Patient rallied well following the opera- 
tion. At the end of three weeks the 
stump was dressed for the first time and 
found to be clean, sweet and perfectly 

Patient was now gotten upon a chair, 
then on crutches and at the end of seven 
weeks was discharged. He has reported 
several times by letter during the past few 
months and is' doing very nicely. Is in 
better general health than he has been for 

It is to the last case I would particularly 
call attention as I think it shows the ad- 
vantages of a high operation. The case 

July 1, 1893. 

Society Reports. 


did not present any favorable symptoms ; 
the patient was weak and emaciated ; had 
been suffering very severe pain for months 
and was very nervous and excitable. His 
arteries were very brittle. The gangren- 
ous process was slowly extending up the 

foot, nearly the whole of which showed 
signs of inflammation. The result ob- 
tained from the operation, however, could 
not have been better for there was left a 
firm, solid stump which he will be able to 
use with perfect safety. 



Stated Meeting, April 10th, 1893. 

Dr. JoHisT C. Cecil, President, pro 
tem.^in the Chair. 


Dr. Turner Anderson: This young 
man five months ago received a. cut in the 
hand from a wood chisel; he suffered 
very little at the time and the wound 
healed. About a month after he began 
to suffer considerable pain and the thumb 
began to swell. He went on working as 
usual notwithstanding the inflammation 
and pain. 

I think the treatment is plain ; there is 
every appearance of pus and I believe it 
will only be necessary to make an incision 
and clean it out thoroughly. This is 
what I propose to do. 


Dr. a. M. Vance: Dr. Anderson's 
suggestion as to treatment in this case I 
believe is the only rational procedure, and 
there is no doubt in my mind but the 
trouble will be completely relieved by 
such an operation. 


Dr. W. L. Rodman: I saw this young 
man with Dr. Chenoweth, and I am sorry 
the doctor is not here to give the history 
in detail. I first saw the patient at the 
University Clinic and asked him to come 
out to my office that I might get the 
whole history. I have a memorandum on 
a card which I will read, it being a few 
points in regard to the history that I was 
able to elicit from the patient himself : 

R. C, aged sixteen years; parents living 
and in good health. Gives no special 
history of tuberculosis; several brothers 
and sisters living and in robust health. 
Two brothers died during infancy. Eelt 
perfectly well until December 1st, 1892 ; 
at that time commenced to have daily 
chills about two o'clock P. M., followed 
by fever and sweats. December 20th, 
right arm commenced to pain him at the 
elbow. December 26th, noticed swelling 
for first time; swelling greater at elbow 
joint, but not marked at any point. At 
that time he thinks the swelling was 
about half as extensive as it now is. 
AVhile it was painful he could use his arm 
some. Has had a cough since December 
1st last. Lost about fifteen pounds in 
flesh. Arm has not increased in size for 
six weeks. I would like to have the 
opinion of the society as to diagnosis and 


Dr. Turner Anderson: Is there 
evidence of disease of the lung ? 

Dr. W. L. Rodman: Yes, in the 
lower part of the right lung. 

Dr. W. C. Dugan: I operated upon a 
patient having a condition very much like 
this at the City Hospital during my term 
of service there last year. Patient had 
been treated a number of months for 
rheumatism and was referred to me from 
the medical ward. I resected the arm 
and found it was a condition of refying 
osteitis; removed the olecranon process, 


Society Reports. 

Vol. Ixix 

found the bone perfectly soft; and with a 
pair of forceps I clipped off the condyles, 
being careful not to interfere with epi- 
condyles to which the lateral ligaments 
are attached. There was a good deal of 
OBdema of the arm, which soon dis- 
appeared. This patient has a good limb 
with almost perfect flexion and extension 
and has regained his health. 

In regard to treatment in case referred 
to by Dr. Rodman: I would excise the 
elbow, and treat it openly with iodoform 

De. a. M. Oartledge: I think it is 
a case of tubercular arthritis, although 
the shape is a little unusual. The 
amount of induration on one side seems 
unusually low, and looks a little curious. 
T take it that there is very likely synovitis 
as well as osteitis. I agree with Dr. 
Dugan that resection is the proper pro- 

De. H. H. Grant: From the exami- 
nation I made of the case I think it is 
tubercular arthritis ; there can scarcely be 
a doubt about it, but that one doubt 
would be that there might possibly be 
some sarcomatous disease of the joint. 
There is very little effusion. 

De. a. M. Vai^-ce: What part would 
the phthisis play in treatment of the 
joint ? 

De. W. 0. Dugan: I should not con- 
sider it at all. 

De. W. 0. Roberts: I agree perfectly 
with the statements already made, that it 
is clearly a case of tuberculous disease of 
the joint and resection is the thing to do. 

Dr. W. L. Rodman: Everybody has ex- 
pressed exactly the same opinion that I had 
already formed in regard to this case. I 
felt almost positive it was a case of tuber- 
culous disease of the joint, after taking 
the patient to my office and getting the 
history. I believe the joint ought to be 
cut into and very likely resected. 


Dr. a. M. Vance : Here is a specimen 
I removed from a young man twenty-five 
years old yesterday. The tumor was just 
over and a little to the left of the larynx. 
When an incision was made, the cartilages 
were completely exposed. At the time I 
first saw the case I thought the enlarge- 
ment was part of the thyroid gland. I 
saw a similar case in this city some time 
ago, the growth was removed which 

looked and felt very much like thyroid 
gland. The history was substantially the 
same as that of the case reported to-night. 
In the operation yesterday I found a great 
blood supply to the tumor, three very 
large vessels; owing to this I was more 
convinced than ever that I had removed a 
portion of the thyroid gland. Dr. Rod- 
man saw the specimen shortly after the 
operation, and thought the trouble was 
probably lymphatic. Microscopical ex- 
amination, however, proved it to be thy- 
roid gland. I will quote the microscop- 
ists report: 

"Louisyille, Ky., April 9, 1893. 
Dear Doctor: 

The growth left me has all the ap- 
pearance macroscopically of thyroid gland 
tissue, and thus it proves itself to be 
upon microscopical examination ; con- 
sisting of a frame work of fibrous tissue 
enclosing glandular spaces, lined with 
small, flat epithelial cells. The glandular 
spaces are in part filled with a homeo- 
genous material (colloid), others are filled 
with round cells (lymph cells). 

Diagno&is — Thyroid Gland. 

Yours sincerely, 

Louis Frank. 

Dr. a. Morgan Vance." 

This is the second case of the kind I 
have seen in the last twelve months. 


Dr. E. R. Palmer : Was there much 
hemmorhage during the operation ? 

Dr. a. M. VanC!E: There would have 
been had I not used clamps. 

Dr. W. L. Rodman: I saw Dr. Vance 
shortly after he removed this growth and 
he asked me to look at it and give my 
opinion upon it. I looked at the specimen 
rather carefully ; it was not opened at the 
time, and told him after my examination 
that I thought it was a lymphatic gland. 
I am more certain of that position now 
since it has been thoroughly opened, not- 
withstanding the microcopist^s report. It 
has every appearance in the world, color 
and everything else, of a lymphatic gland, 
and I am reasonably sure that is what it 
is. It does not look like thyroid tissue. 
I have dissected a hundred thyroid glands, 
and am sure they did not have this ap- 
pearance. The history of the case 
furthermore points clearly to lymphatic 
enlargement rather than to disease of the 
thyroid gland. We do have growths of 

July 1, 1893. 

Society Reports, 


the thyroid that occur sometimes from an 
accessory portion, but as I have said 
before this does not look anything like 
thyroid tissue. Thyroid tissue is purplish 
red, about the color of liver. 

Dr. a. M. Carteedge: I would sug- 
gest that Dr. Vance have Dr. Frank make 
some additional sections in this case. If 
it is thyroid tissue it has every appearance 
of having undergone malignant degener- 
ation. I agree that it does not look like 
thyroid tissue. T know of no change that 
the thyroid body is subject to which 
would give it such an appearance, unless 
it be sarcoma. I have never seen so much 
connective tissue in any form of goitre as 
there is in this case, and I am not aware 
of any pathological condition that would 
give it this appearance. However, the 
microscope ought to show just what it is. 

Dr. a. M. Vai^ce: G-oitre aifects the 
central lobe of the thyroid, the shape 
being caused by pressure of the skin over 
the hypertrophy. In the case reported by 
me the thyroid gland on every side looked 
like this tissue when it was exposed. 
This is evidently the isthmus hypertro- 

Dr. W. L. Eodman: Benign growths 
from the thyroid gland are practically un- 
known. The only benign growths or 
enlargements that we have of the thyroid 
are originally cases of hypertrophy or 
bronchocele, and then cystic degeneration 
of the gland. Malignant disease does 
sometimes occur, but it is exceedingly in- 
frequent, so infrequent that I doubt if 
any gentleman here has ever seen one. I 
have never seen one, and in th« absence 
of benign growths from the thyroid, the 
comparative rarity of malignant growths 
of the thyroid, with the history of this 
case I feel quite safe in saying that it is an 
enlarged lymphatic gland. 

Dr. a. M. Vance: I have very little to 
add in closing. Certainly I would rather 
take the testimony of Dr. Frank (who is 
recognized as one of the best and most 
accurate microscopists in the city) after 
a careful microscopical examination, than 
the opinion of Dr. Eodman or, in fact any- 
body else, based upon a macroscopical 
examination of the specimen. If Dr. 
Eodman will specify some anatomist that 
he would like to make further investiga- 
tion of the specimen, I shall be very glad 
to send a portion of the growth to him. 
Or if he prefers, I would be gladr to divide 

the specimen with him, that he may have 
it examined by anybody he desires. 


Dr. H. H. Grakt: I have a specimen 
here which is the result of an intestinal 
resection made upon a living animal two 
weeks ago. After killing the animal I 
removed about eight inches of the gut 
embracing the portion resected, which has 
not yet been opened, as I wished to exhibit 
it here with a view of showing how much 
the lumen of the bowel is diminished, if 
any; and also to see the result of the 
resection generally. The animal was 
thoroughly anassthetized, the incision made 
and several inches of the intestine exposed ; 
resection was quickly done by the aid of 
the clamp devised by myself which I pre- 
sent here for your inspection, and which 
was also shown at the meeting of the 
Southern Surgical and G-ynecological 
Society several months ago. The animal 
was under chloroform thirty-five minutes, 
eleven minutes were occupied in suturing 
the intestine; the ends were invaginated 
in the usual way, continued suturing being 
employed. By an examination of the 
specimen you will see there is very little 
contraction; the sutures have been com- 
pletely buried; there was no peritonitis; 
the animal did remarkably well after the 
operation, and the result is perfect. The 
operation was done very leisurely, and I 
am satisfied it could be easily completed 
in twenty minutes. No plate of any kind 
was used. I have made this experiment 
several times, using only one line of suture 
and the result has been perfect, except in 
one instance. 

This clamp is used only for resection ; 
the ends of the intestine are laid parallel 
with each other, and the suturing done 
while the clamp is in situ. It 
shortens the operative steps very much, 
renders approximation of the openings 
absolutely accurate, and defines the limit 
of the fenestra beyond chance of error. 
Such a clamp takes the place of skill to a 
considerable extent. 


Dr. W. C. Dugan: The clamp cer- 
tainly shortens and simplifies the opera- 
tion very much indeed. The clamp 
designed by Dr. Grant is the best con- 
trivance for the purpose that I have ever 


Society Reports. 

Vol. Ixix 


Dr. W. 0. Egberts: This specimen is 
simply a vulvo- vaginal gland dissected out 
to-day. The patient was a young widow 
who noticed this growth three years ago, 
and claims that a short time before the 
appearance of the growth she was consid- 
erably bruised during coitus with her 
husband, that there was a good deal of 
swelling about the parts and some time 
after that while bathing she noticed this 
lump. She has been worrying a great 
deal about the matter, simply from the 
fact of the growth being there, and came 
to the city to have it removed. I have 
seen a good many such cases and have 
usually laid them open, not finding it nec- 
essary to dissect them out. However, in 
this case the patient was very anxious to 
have it removed, which was done very 
easily and quickly. 


Dr. W. L. EoDMAif: Was the growth 
on the left or the right side? 

Dr. W. 0. Egberts: On the leftside. 

Dr. E. E. Palmer : I see quite a num- 
ber of these cases, and the question asked 
by Dr. Eodman brings up a point that I 
had not thought of before ; in three of the 
cases recently seen by me the enlargement 
was on the right side. I have never re- 
moved but one of them in toto. When 
this complete operation is done there re- 
mains a depressed, hard cicatrix at the 
point of removal, which is entirely 
avoided when these glands are simply 
opened, curetted and packed and provided 
the operation is thoroughly done, the cure 
is equally assured. 

With reference to the etiology, I be- 
lieve almost invariably that the condition 
is of gonorrhoeal origin. It is hard to 
say that this is absolutely the case, but I 
believe in the vast majority of cases it can 
be traced to gonorrhoea. The usefulness 
of the gland is permanently destroyed by 
these enlargements so far as future func- 
tion is concerned, whether they be dis- 
sected out or curetted and packed; the 
secretion is unilateral afterward, that is, 
is confined to the side not diseased. 

Dr. W. L. Egdman": I have seen I 
think five or six cases of enlarged glands 
of this character in my experience, and 
my observation has been different from 
that of Dr. Palmer ; I have never seen but 
one on the right side. I would like to 

ask Drs. Anderson and Cecil what their 
observation has been in cases occurring 
after labor as regards the side affected, 
and their explanation as to why the left 
side is more frequently diseased than the 
right. It has not only been my exper- 
ience that the left side is far more often 
affected than the right, but in looking the 
matter up several months ago, I found 
that the vast majority of these enlarged 
glands occurred on the left side. The 
only case I ever saw occurring on the 
right side was the last case I saw which 
was two or three months ago, a patient of 
Dr. McDermott's. The enlargement was 
noticed soon after child-birth, patient 
forty-five years of age. 

My experience differs again with that of 
Dr. Palmer. I do not think I have seen 
any cases where they could be traced to 
gonorrhoea. Most of the cases I have seen 
have been after child birth, in a class of 
patients above suspicion. 

Dr. Turner Akdersgk: With refer- 
ence to the location of these enlargements, 
I do not think I have seen them more fre- 
quently on the left than on the right side. 
Concerning the etiology — it is my opinion 
that the majority of them occur from gon- 
orrhoea! infection. At least I have seen 
more cases among prostitutes than any 
other class of women. There is another 
point of some importance in connection 
with the etiology. Occasionally after 
perineorraphy, obstruction of the external 
duct is sufficient to cause cystic degenera- 
tion of the gland, — which we must recol- 
lect is of the same character as the mam- 
mary and other glands of the body, and 
just as liable to undergo cystic degenera- 
tion. I have a case now that came to me 
a few days ago with a tumor in the left 
side of the vagina which I diagnosticated 
without any difficulty as an enlarged 
vulvo-vaginal gland, which has probably 
undergone some kind of degeneration, as 
it has attained a considerable size. This 
patient was operated upon in Cincinnati 
for lacerated perineum, and it is probable 
there is obstruction of the external duct, 
which we know opens just within the 
ostium vagina. I do not expect to find an 
abscess, but believe the function of the 
gland has been interfered with by occlusion 
from the operation of perineorraphy. 
The case was a satisfactory one as regards 
the operation, but it has probably ob- 
structed the gland. This is a matter that 

July 1, 1893. 

Society Reports. 


ought to be taken into consideration in 
perineorraphy, but at the same time I do 
not see how it can well be avoided. 

With reference to the point raised by 
Dr. Palmer concerning the treatment of 
these cases — incision and packing, and in 
that way preserving the symmetry of the 
parts, preventing shrinkage or depression 
— I do not know that my attention has 
been especially directed to that. The 
usual operation is to simply incise the 
gland, pack and let it heal from the bot- 
tom. But in the case just referred to, 
upon which I shall operate in a few days, 
I believe I will adopt the plan followed by 
Dr. Eoberts, and dissect out the gland 
bodily. I think this is advisable owing to 
the size of the gland. 

De. J. G-. Cecil : The point made by 
Dr. Palmer seems to me to be the correct 
one in regard to the etiology^ as far as my 
reading and observation go, that these 
enlarged glands are largely due to gonor- 
rhoeal infection. The point made by Dr. 
Anderson concerning the class of patients, 
I think will be borne out by observing the 
patients in which these troubles are usu- 
ally found. Certainly, I have seen more in 
prostitutes than any other class of women. 
I do not see how they can follow as a 
result of labor, unless it be in the manner 
already described by Dr. Anderson as fol- 
lowing the operation of perineorrhaphy; 
that is after the duct was torn across in a 
lacerated perineum, then we might have 
occlusion of the duct and cystic degener- 
ation result. I can conceive how that 
might follow as a result of labor, but I 
cannot see how there could be any other 
method of degeneration or abscess as a 
result of labor. 

I was quite impressed with the descrip- 
tion, or method of operating described by 
Pozzi. It is sometimes very difficult in 
dissecting this gland out, especially when 
it is simple cyst, to prevent rupture ; as 
long as we can prevent rupture dissection 
is easy enough, but if rupture occurs then 
it becomes more difficult, then complete 
dissection is advocated, it being difficult 
to follow the cyst wall after it is empty. 
His method is described about as follows : 
He introduces a trocar and canula withdraw- 
ing the fluid before he attempts to operate, 
fills it with a warm solution of paraffine, 
then the application of cold converts the 
paraffine into a solid tumor, which makes 
a very nice ground to work upon. 

I am inclined to the belief that the 
total obliteration of these glands is the 
proper treatment. Of course the func- 
tion is destroyed if an incision is made 
and the gland packed; if there is an 
abscess or cystic degeneration they are of 
no further use and might as well be 

I have never noticed any particular 
diffierence in the two sides, and think 
they are as apt to enlarge on one side as 
the other. 

Dr. W. 0. Egberts: I have seen a 
number of these cases occurring in other 
than prostitutes. I can recall now three 
cases in newly married women. This, I 
take it, is cystic degeneration; I do not 
think there is any pus in it ; it has existed 
too long, something over three years. 

Note : The tumor was opened by Dr. 
Eoberts and found to be cystic. 

Joseph M. Mathews, M.D., then read a 
paper on 


About one year ago, I had the honor of 
reporting to this society some investiga- 
tions that I had been making of diseases 
in the sigmoid flexure. The paper elicited 
considerable discussion, and I was asked 
to prolong the report at the following 
meeting of the society. Inasmuch as the 
subject was treated at length in my work 
on diseases of the anus, rectum and sig- 
moid flexure, which appeared shortly there- 
after, the second report was never made. 
From the friendly reviews of this chapter 
in the book and from many letters of com- 
mendation that I have received from the 
profession, I take it that the discussion of 
the subject was not inopportune. This 
paper is intended only to give a recitation 
of some cases that have fallen under my 
observation lately and to mention some 
procedures looking to the surgical treat- 
ment of the same. Although recognized 
from all time that the sigmoid was a favor- 
ite seat of disease, but little was done for 
its treatment, either in a medical or surgi- 
cal way, until recently. As far as my 
knowledge goes, Dr. W. T. Bull was the 
first to successfully remove the sigmoid 
flexure for malignant disease. A few 
months ago Dr. Lange reported three cases 
of a similar kind, with one success. It 
must be understood that success means, at 
least in Dr. Lange's cases, the survival of 


Society Reports. 

Vol. Ixix 

the patient from the operation. The time 
is too short to say whether the eradication 
of the disease is effectual. Dr. Bull claims 
that his patient lived five years after the 
operation. In a note to me concerning 
the case he says,'" The carcinoma was ex- 
cised in January, 1887 ; she was in good 
health up to October, 1891, and there was 
no recurrence at the autopsy in December, 
1891, being nearly five years." Senn has 
never been a believer in colotomy for any 
condition, but he has devised other opera- 
tions to meet the demand. He has anas- 
tomosed the ileum into the rectum, and 
also the colon to the rectum, saccessfully, 
and claims, as a result, that if stricture of 
the sigmoid is to be overcome, his opera- 
tion would be preferable to an artificial 
anus, if the opening where the anastomosis 
was made did not with time contract too 
much. To carry out the idea of Marphy, 
that,by using his button, anastomoses of the 
intestine could be made either end to end 
or lateral in a few minutes. Dr. Joseph B. 
Bacon, of Chicago, has just recently been 
"making some very interesting experiments, 
looking to the surgical treatment of non- 
malignant stricture of the sigmoid flexure 
or rectum. Because of the importance and 
newness of the subject, I will be permitted 
to quote freely from a late article by Dr. 
Bacon, describing the method. "The 
operation consists in completely severing a 
portion of a loop of small intestine that is 
lying in proximity to the rectum and anas- 
tomosing each end with the rectum, so as 
to form a new channel around the stricture. 
The mesentery of the severed piece of gut 
is left intact. A piece of intestine is 
selected from the loop, at a point where 
the mesenteric blood vessels supply a large 
nutrient artery for each end of the piece 
to be transplanted. It is necessary to re- 
member, in cutting out a piece for trans- 
planting, that it must be long enough to 
extend from a point below the stricture to 
a point above the stricture where the rectal 
wall is not too much thinned by ulcera- 
tion; and also to remember that the but- 
ton to be inserted into each end will shorten 
the piece about one and a half inches. 
The operation is completed by scarifying 
the approximated surfaces of the rectum 
and transplanted piece of gut and suturing 
them together, so as to have the two walls 
united into one firm septum. At a sub- 
sequent operation this septum is removed 
by compression forceps and the lumen of 

the rectum and transplanted piece is made 
into one cavity, and the sloughing out of 
the compression forceps will destroy one- 
half of the stricture, together with the 
septum, thus putting an end to the con- 
traction of the cicatricial tissue forming 
the stricture. The mesentery of the 
transplanted piece of gut is sutured in 
close approximation to the parietal wall, 
to prevent a possibility of a loop of intes- 
tine sliding under it and becoming stran- 
gulated. A Murphy button is now used 
to make an end to end anastomosis of the 
gut, from which the transplanted piece 
was resected and its mesentery sutured 
carefully, so as to leave no opening for 
hernia to occur." 

I will make this report by Dr. Bacon 
suffice for any further mention or discus- 
sion of the surgical treatment in such 
cases, reserving the right to discuss this 
method in some future article. 

There are several conditions which, if 
left alone, will produce such pathological 
changes in the sigmoid flexure as to call 
for the surgical interference as suggested 
by Bull, Senn, or Bacon, and yet, if these 
conditions are recognized early, can be 
prevented from such ultimate results. I 
must confess that after a stricture has 
formed at the sigmoid or in the rectum, in 
the great majority of cases no good can 
come from the treatment of the stricture 
per se, and recourse must be had to such 
procedures as those mentioned in this 
paper. And in this day, when such asep- 
tic surgery can be done in the peritoneal 
cavity, I see no reason why such attempts 
as suggested by Dr. Bacon should not be 
undertaken. But as prevention is better 
than cure, I will conclude my paper by 
dealing with the treatment of such con- 
ditions as give rise to the necessity of such 

The sigmoid flexure is peculiarly liable 
to local disease. Outside of malignant 
affections its anatomical arrangement is 
such, that it is made the receptacle of the 
faeces, both as the mass is attempting to 
pass, out in the act of defection, and the 
remaining portion is pressed back by an 
anti-peristaltic movement. Hence it is no 
wonder that it is subjected to congestions, 
inflammations, ulcerations,- etc. , and these 
combined frequently establish non-malig- 
nant strictures. I have tried to demon- 
strate in a former article that the flexure 
was often, I might say commonly, the seat 

July 1, 1893. 

Society Reports, 


of impaction by faeces, and the fatality of 
such impactions sometimes all can attest. 
In addition to many cases of sigmoid dis- 
ease that I have already related, I now de- 
sire to call attention to but a few : 

No. 1. Mr. J., aged twenty-eight. By 
occupation a civil engineer. About five 
months ago complained of a slight diarr- 
hoea. He consulted a physician, who gave 
him the usual remedies for such cases, but 
the discharges increased, from four or five 
daily, to twelve or fifteen in the twenty- 
four hours. His condition growing serious, 
and his disease not responding to internal 
treatment, his physician sent him to me, 
thinking that the cause might be found in 
the rectum. His diarrhoea had now con- 
tinued five months and he had lost forty 
pounds of flesh; no energy, and all appe- 
tite gone. An examination was now made 
of the discharges and they were found to 
be composed of blood, mucus and pus. 
Not dysenteric, as no elevation of temper- 
ature or pulse occurred at any time. An 
examination of the rectum revealed an ex- 
tensive ulceration, beginning about four 
inches up and extending evidently into 
the sigmoid flexure. This man gave no 
history of syphilis. I had him discontinue 
all internal medication, go to an infirmary 
and observe perfect rest in bed, first giving 
him a free purge. I then washed out the 
sigmoid with hot water. He was put on 
a special diet and the local treatment be- 
gun, which consisted in depositing in the 
flexure daily one ounce fluid hydrastis 
diluted with two ounces of water. From 
the first injection the discharges began to 
assume a natural condition, and at the end 
of ten days all mucus, blood and pus had 
disappeared. In this time his appetite 
had returned and he began to take on 

flesh, although on a liquid diet. At the 
end of two weeks he left for Chicago with 
directions to inject the sigmoid every alter- 
nate day. This case is but a sample of a 
number that I had to report, but my time 
being limited, will make this one suffice 
for the evening. 


Dr. H. H. Grant: Could the small 
bowel be made to do the duty of the rec- 
tum in case of anastomosis? Would not 
the fecal matter block up below where the 
transfixion was effected ? Would it not be 
better, in other words, to make an artifi- 
cial annus, as it is now made, for the re- 
lief of these conditions? 

Dr. J. M. Mathews: I suggested 
that it might be better than a colotomy, 
and for that reason suggested that it 
might be better to anastomose the sigmoid 
flexure or the colon to the rectum, as 
practiced by Senn than to attempt the 
operation suggested by Bacon. 

Dr. W. L. Eodman: I think Dr. 
Mathews has called our attention to a 
very important matter, that is, flushing 
the sigmoid flexure. For this purpose I 
believe the rectal bougie preferable to the 
tube, as the latter is liable to curve upon 
itself. I have seen harm result from the 
use of the tube. I once made a post 
mortem upon a patient of a medical friend 
who had been treated by local applications 
for dysentary through a rectal tube fully 
eighteen inches in length. The patient 
died of peritonitis. In making the post 
mortem I found the belly full of fluid, 
soap-suds, etc., used in the injections, 
which had passed out through a perfora- 
tion of the gut made, I think, by the 


Meeting, May 2Jfth, 1893. 

Dr. Mordecai Price presented a Report 
of Interesting Cases in Abdominal Surg- 
ery. (See page 15.,) 


Dr. Joseph Hoffman": Dr. Price stated 
that in the cases on which he had operated 
he had not met with high temperature ex- 
cept in two instances. The question of tem- 

perature is an interesting one. In one of 
the most serious cases of appendicitis the 
temperature was not markedly high, al- 
though there was gangrenous gut and ab- 
scess. The pain and tenderness were, 
however, marked. I have seen a case in 
a young child where the temperature was 
abnormally high. 


Society Reports. 

Vol. Mx 

"With regard to operation : I am puzzled 
to decide in what cases operation should 
be done. I have seen cases in which the 
condition seemed to be imminent, recover 
without operation, and I have seen cases 
apparently parallel die. Where the line is 
to be drawn between the cases that will re- 
cover under medical treatment and those 
in which operation is required is difficult 
to decide. Within a week I was called to 
see a boy eighteen years of age in a second 
attack. There was high temperature and 
a mass easily to be made out. The bowels 
had been bound up, and no relief was af- 
forded by anything that had been done. 
I put the boy on purgative medicines and 
within forty-eight hours there was a re- 
duction of temperature, and in another 
forty-eight hours the abdomen was per- 
fectly pliable and the boy apparently well. 
I suggested operation, but it was not ac- 
cepted. Whether or not this trouble will 
come back, I cannot say. 

Dr. Addikell Hewson : I have made 
some investigations in the dead body with 
reference to the position of the appendix. 
I examined some 74 bodies. In this num- 
ber I found evidence of appendicitis of 
more or less severe degree in 23 cases. 
Only one showed that there had been 
operative interference. The investigation 
was not made to determine the presence 
of appendicitis, but simply to obtain ana- 
tomical data by which the position of the 
appendix could be more definitely reached. 
The position of the appendix varied con- 
siderably. In one instance it was in con- 
tact with the under surface of the liver. 
In many instances it was in the cavity of 
the pelvis. In many it was above the 
crest of the ileum, and in the majority of 
cases the base of the appendix was above 
the inter- iliac line — this is the line drawn 
from one anterior superior spinous process 
to the other. I made some notes in refer- 
ence to other points in connection with the 
appendix, but they are not germain to the 
discussion. I merely wish to recall the 
fact that there were evidences of appen- 
dicitis in 23 of the 74 cases. 

The results of examinations will be pub- 
lished later in the Amer. Journ. Med. 

Dr. Daitiel Lon'GAKEr: It seems to 
me that the last case reported is only ex- 
plicable on the assumption that, as a result 
of rude manipulation, some focus of pre- 
existing disease was disturbed, or, if the 

trouble was not produced in that way, it 
must have been set up by the production 
of endometritis and extension from this 
point. I assume this from an experience 
that I have had. A woman supposed her- 
self pregnant and introduced a knitting 
needle into the uterus. She experienced 
no pain at the time, but in the course of 
a few weeks there was severe suffering and 
septic endometritis. Whether or not she 
was pregnant was never ascertained. The 
inflammation soon extended and involved 
the tubes, and in a few weeks there resul- 
ted a large tubo-ovarian abscess and a de- 
cided attack of pelvic peritonitis. The 
trouble was promptly removed ; but I may 
say that the endometritis still lingers, and 
will probably require a second operation, 
that of curettement. I would ask whether 
or not this condition exists in the case re- 
ferred to by Dr.. Price. 

Dr. James Collins : Eegarding the 
relations of medical and surgical treat- 
ment in appendicitis, I am sorry to report 
that I have seen several patients die in 
whom I had advised operation, but was 
overruled by the medical attendant. I 
have seen one or two saved, but that is 
such a limited number that I dare hardly 
speak of it in connection with the number 
of cases reported to-night. I suspect that 
it is safe treatment, where the obstruction 
and symptoms of appendicitis continue 
after the second day, to consider the advis- 
ability of surgical interference, and espec- 
ially so if there is present a sign not often 
mentioned, which in the male is pain in 
the line of the cord and testis. In one 
or two cases the medical attendant has 
taken the ground that because there was 
no high temperature there could not be 
any very serious inflammation in progress. 
I have for many years advocated operation 
in appendicitis, and I have said that I 
would never let another case where there 
were evidences of peritoneal inflammation 
die without operation. 

The President, Dr. De Forest Wil- 
LARD : I am glad that Dr. Price empha- 
sized the point of low temperature which 
is so common. It seems that in these 
cases the temperature is positively no in- 
dication of the severity of the case, and 
is not to be relied upon unless it is very 
carefully watched. There are certain cases 
where, if it can be watched day after day, 
it then becomes an important element in 
diagnosis and prognosis. 

June 1, 1893. 

Society Reports, 



In common with Dr. Hoffman, we are 
all seriously puzzled to draw the line 
between the cases that will recover with- 
out operation and those which should be 
operated upon. This subject cannot be 
discussed too frequently, and every case 
should be recorded and thorougly consid- 
ered and studied. 

De. Geoege E. Shoemakee : The 
point of diagnosis is one of great interest, 
and those who have had surgical experi- 
ence with appendicitis should emphasize 
the fact that there are no signs which are 
absolutely reliable. Dr. Willard will re- 
call a case which I recently reported, and 
which he afterward saw, where there was 
gangrene of the appendix and where there 
was no tumor; where there was no ten- 
derness in the rectum, and where there 
was no tympany. The belly was scaphoid, 
and yet there was gangrene of the appen- 
dix, with perforation. I was utterly de- 
ceived as to the necessity for operation in 
a case which occurred several years ago. 
A German woman of exceptionally good 
physique, and whom I knew to have no 
uterine or tubal disease, was suddenly 
taken with chill and pain in the right 
iliac fossa. The temperature went up to 
104°, and the symptoms persisted for four 
days. I considered the case to be one of 
appendicitis, feared pus, and advised op- 
eration. I had a consultant who also 
advised operation. The patient refused 
^nd asked to see still another consultant, 
and in the twelve hours of consequent 
delay her condition completely changed 
for the better, the temperature went down 
and in time she made a complete recovery 
without operation. Within a few days she 
passed pieces of tapeworm, which proba- 
bly had been the exciting cause of the 
appendicitis. As a contrast to this unex- 
pected recovery, on the very day of my 
proposed operation a young man died in 
this city because he had a pint of fetid 
pus about his appendix, and because one 
of the most capable diagnosticians any- 
where denied its presence till too late. The 
great majority of cases that I have been 
called upon to observe have gotten well 
without operation, because pus did not 
form. But the attacks recur. This ques- 
tion is one of gravity. A gentleman came 
to me to-day to know what I would advise 
in a case which I had seen some years ago 
with him. The patient then had appen- 
dicitis and recovered; but the attacks 

have recurred, gradually becoming more 
severe and the intervals shorter. I said 
that in such a case operation was advis- 
able, but each case must be studied by 
itself. There are no definite rules, and 
never will be. 

De. William M. Welch : I have seen 
a few cases of appendicitis, and recall 
some four or five that have recovered with- 
out operation. Still I am inclined to 
think that surgical interference is a mat- 
ter to be thought of in all such cases. 
Last summer I saw a case in consultation 
where I proposed that a surgeon be sent 
for with a view of considering the pro- 
priety of an operation; but the patient 
positively refused, and after suffering for 
two or three months recovered, as I be- 
lieve, perfectly. One of my cases, a child, 
developed an abscess, whicJi discharged 
through the umbilicus for a considerable 
time; but even this was followed by re- 

You will remember, Mr. President, that 
a year ago a discussion took place here on 
this subject, and that the surgeons insisted 
that an operation should always be thought 
of, while the physicians held that surgical 
interference was required only in a small 
proportion of cases. There was present 
at that meeting a layman of considerable 
prominence who told me the next day he 
was deeply interested in the discussion, as 
he had recently gone through an attack of 
appendicitis; that the surgeon who was 
called in consultation advised operation, 
while his attending physician opposed it. 
He said he followed the advice of his 
physician and is glad that he did so. I 
mention this to show that recovery from 
appendicitis may follow medical treatment 
when surgical interfence is thought neces- 

De. James P. Mann : I wish to say a 
few words in regard to two cases that have 
come under my notice. One was a phy- 
sician, a friend of mine, and a man of 
considerable surgical experience, especially 
in abdominal work. He simply felt sick, 
but had no pain and no elevation of tlm- 
peratare. There was a little constipation. 
A diagnosis could not be made, until, 
finally. Dr. Wyeth, of New York, inserted 
his finger into the rectum and found a soft 
tumor on the right side. He then hazard- 
ed a diagnosis of appendicitis. The case 
was operated on and twelve ounces of pus 
removed, with recovery. 


Society Reports. 

Vol. Ixix 

The second case was that of my son, 
two-and-a-half years old. He was taken 
sick in the night and appeared to have a 
little pain in the abdomen. 

The temperature remained normal. The 
case was seen by Drs. Joseph Hearn, A. 
Gr. Hinckle, and Allis. For the first 
three days there was some obstruction of 
the bowels, but that passed away under 
simple treatment. The child seemed to 
be improving, but at the end of a week 
he suddenly went into collapse and died 

The post-mostem showed that there had 
been appendicitis with rupture and gen- 
eral peritonitis, and all this without any 
symptoms of appendicitis that could be 

Dr. G. BETTOis^ Massey: I have seen 
two cases of appendicitis that have led me 
to certain conclusions in the matter. The 
first one was a gentleman of prominence 
in the city, who had been nursed through 
seven attacks of appendicitis. This man 
was almost black from the prolonged use 
of nitrate of silver. Some months after 
I saw him he died in a recurrent attack. 

The second case occurred recently in a 
young woman. The attack was diagnosed 
by myself and others as a second attack of 
appendicitis. I advised the patient to put 
herself in the hands of a surgeon for 
operation after recovery. This she did 
not do. Three months later she had an- 
other attack and died. Of course, this is 
a small number of cases .to form a judg- 
ment upon, but it leads me to the conclu- 
sion that surgery is the best treatment, 
at least after the second attack — not dur- 
ing the attack but in the interval. 

The Presiden^t, Dr. De Forest Wil- 
LARD : Dr. Welch is in error in intimating 
that the surgeon, ' ' of course, urges oper- 
ation." A few years since this subject 
was discussed independently by two socie- 
ties. The Association of American Physi- 
cians and the American Surgical Associa- 
tion. The consensus of opinion in the 
surgical society was rather against the 
operation ; that it was an exceedingly dif- 
ficult and dangerous one, and that it often 
was impossible to find the appendix; 
while the physicians strongly advised oper- 
ation, and the speakers considered it to be 
perfectly simple, and held that no one 
would have any difficulty performing it. 
From my own experience, and I have seen 
a large number of these cases in the past 

few years, I am sure that surgeons refuse 
operation in a far larger number of cases 
than they operate upon. The surgeon is 
often obliged to restrain the physician in 
his desire for operation. 

Dr. Price : In my estimation, there is 
only one treatment for suppurative appen- 
dicitis. I do not mean by appendicitis 
simply irritation of the appendix, but I 
mean inflammation of the appendix going 
on to ulceration and rupture. One physi- 
cian asserted, in the discussion referred to 
by Dr. Welch, that if all these cases were 
operated upon there would be 20 per cent, 
more deaths than at present. The opera- 
tions of surgeons in this city will positive- 
ly refute that statement. I can give a 
hundred cases, in the hands of a dozen 
men, with not more than ten or twelve 
deaths. An appendix operation has no 
business to kill, and the man who cannot 
find the appendix either does not know 
where the appendix is, or he has another 
condition, in which he has no business to 
hunt for the appendix. If there is an 
abscess at the head of the colon, with the 
peritoneum shut off, it should be opened, 
washed out, and packed, and the patient 
will get well. No effort should be made 
in these cases to find the appendix. 

With regard to the symptoms of appen- 
dicitis, I think that they are plain. If in 
the first twenty-four or forty- eight hours 
you find a tumor, that is not appendicitis. 
An. abscess of such size does not form in so. 
short a time. There may be high tem- 
perature; that has nothing to do with 
appendicitis, «necessarily. There is an 
impacted colon and something irritating 
the colon. The administration of salts, 
persisted in until free evacuation of the 
bowel is produced, often cures the patient. 
If called to a patient with symptoms of 
appendicitis and you administer a purga- 
tive, and, coming back after free purga- 
tion, you find 'the mass and swelling and 
the patient no better, you have a case of 
appendicitis every time; you have an ab- 
scess forming at the head of the colon. 
It is your business to cut down and drain 
that, and if you open the peritoneal cav- 
ity it does not matter. If you wash out 
the peritoneal cavity and put in a gauze 
drain the patient will recover. When you 
find a man with a pulse of 170, where a 
grain of opium, or two or three grains, an 
hour have been given, with all the symp- 
toms smothered, with a mass in the right 

July 1, 1893. 

Society Reports. 


iliac fossa, and a temperature of 97°, re- 
spirations reduced to ten or twelve per 
minute^ let him alone. Such a patient is 
beyond all possible chance of recovery. 

We must recognize that all the troubles 
in the right iliac fossa are not appendicitis. 
Unless we have positive proof that there 
is trouble, we should not interfere. 

In regard to Dr. Welch's cases. Pa- 
tients do recover with abscess at the head 
of the colon ; but is that treatment ? Be- 
cause now and then a man falls off a house 
and is not killed, it does not follow that 
that is a good way to get down. We have 
no business to call that treatment. It is 
our duty to do that which we find best for 
the patient, and not run the risk of hav- 
ing the abscess break into the colon or 
other viscera, and matting together of the 
bowels and crippling the patient for life. 
A short time ago I saw, in Albany, one of 
the cases which Alonzo Clark reported as 
appendicitis cured by opium. The man 
said to me that he had carried that appen- 
dicitis with him ever since. It ruptured 
into the bladder, and he passed feces for 
six months. Such cases as this are a proof 
that we should relieve these cases, and do 
it early, in order to avoid those fearful 
accidents which Nature in her attempt to 
save life, brings about. 

I doubt whether Dr. Hoffmann's case 
was one of genuine appendicitis. There 
was trouble there at the head of the colon, 
with inflammation and tumor. 

Dr. Musser had one of the most typical 
cases of appendicitis" without rupture that 
I ever saw. The patient had had three or 
four attacks every, year for several years. 
Dr. Musser diagnosed appendicitis. In 
all the attacks, except the last, the patient 
was relieved by free purgation. Dr. Jo- 
seph Price was then asked to operate. 
The history was clear, the appendix was 
large and distended with pus. The abdo- 
men was opened and the tubes and ovaries 
found healthy. The appendix was not 
adherent and looked well. It was caught 
with haemostatic forceps and tied off. On 
squeezing the removed appendix the nas- 
tiest pus could be squeezed out of it. 

In the seventeen cases on which I have 
operated, I did not remove the appendix 
but twice. The trouble is, that we do too 
much surgery. A surgical operation for 
Tus at the head of the colon, from any 
cause, if done in time, should not have 1 
per cent, mortality. We have come to the 

point where there is but one obstructor in 
appendicitis cases, and that is the general 
practitioner consultant. 

De. George I McKelway exhibited a 


Flatulent Dyspepsia. 

T>. Bicarbonate of soda gr. Ixxv 

JQy Prepared chalk 5i 

Powdered nux vomica gr. xv 

Powd. red cinchona bark 5i 

Make so cachets. 

Sig.— One cachet before each meal. 

— Union Medicals. 

Liniment for Neuralgia. 

T>, Chloroform 6 drachms 

-L)i Sulphuric Ether i ounce 

Spirits Camphor 3 ounces 

Tinct. Opium 1% drachms 

M. Sig.— Soak a small piece of flannel with the lini- 
ment, and apply over the painful part. 

Cramps of the Legs in Pregnant Women. — 
Administer at bedtime five milligrammes of 
sulphate of copper. This can be administered 
every night without inconvenience. — La 
Gazette Medicate. 

For the Night-sweats of Pulmonary Tuber- 
culosis Dr. Ewart {La Semaine Med in Med. 
News,) suggests: 

T> Quininae sulphat., 

XV Zinci sulphat aa gr. ij 

Ext. hyoscyami gr. j 

Ext. nucis vomicae gr- 73 

M.— Ft. pil. j. Sig.— Take at bedtime. 

For Paralysis in Lead Poisoning. 

T> Potass, iodid., 5ij 

XV Ext.ergotfl., §j 

Ext. nucis vom. fl., 5i 

Tr. cardamon co., §j 

Syrup, q. s. 

• Aquae, ad Siv 

M. Sig.— Tablespoonful night and morning. 


Squibb gives: 

■p Tinct. opii 5ii 

JQkj Tinct. capsici 5ii 

Spr. camphor 5ii 

Chloroform m xv 

Alcohol ad 5x 

Sig.— Dose 20 to 40 drops. 

— College and Clinical Record, 


The following, says Buxton Shillitoe, will 
sometimes abort a carbuncle or boil if applied 

T>, Extract opii Sss. 

XV Glycerine, q. s. nt. fiat, magma. 

M. Sig —Smear thickly over the swelling three or 
four times a day; then apply. 

T>. Pulveris opii 1 

-Q^ Unguenti hydrargyri V aa oSS. 

Saphonis durae ) 

M. Sig. — Apply spread on thick leather. 

The Medical and Surgical Reporter 



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NOTICE TO CONTRIBUTORS : — "We are always glad to receive articles of value to the profession, and when used they 
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make a note of that fact on the first page of the MS. It is well for contributors to enclose stamps for postage, that the 
articles may be returned if not found available. 

I ■- — ■ 

Saturday, July 1st, 1893. 




"Witliiii the past few years this qnestion 
has often arisen, and it now recurs with 
emphasis greater than ever, since, in the 
latest issue of the Journal of the American 
Medical Association^ the retiring editor 
attempted to make a plausible explanation 
for a very bad case. 

"When we behold the present strength 
and wealth of the Journal of the British 
Medical Association^ we naturally inquire 
why America cannot maintain a journal 
its equal or superior. But if we consider 
for a moment and investigate, the answer 
is apparent. There is no analogy between 
the medical affairs of G-reat Britain and 
those of the United States. They, as a 
nation, have state medicine and we have 
not. England has no medical weekly of 
importance sufficient to compete with the 
Association's journal save the Lancet^ 
while in America, there are at least a 
dozen journals of commanding merit. 
Over the ocean, the government is mon- 

archial and paternal; tenure of office, 
private and public, has a stability and per- 
manence quite impossible in a democracy. 
G-reat editors are not born or made to 
order every day. It was only a Wakely 
who could found a Lancet^ and before the 
fortunes of the Journal of the British 
Medical Association were placed in the 
hands of Ernest Hart, it had a precarious 
existence, and was given into his charge 
a forlorn hope. Moreover — there is no 
use of disguising it — the average respect- 
able and influential American medical 
weekly is not in sympathy with the full 
development of the '^'association journal" 
idea. Editors and publishers know well 
that to make it in value and influence pro- 
portionate to the mighty nation which it 
should represent, would in one year, sink 
out of sight nine- tenths of the journalistic 
yield of this country. Doctors want to 
edit journals, and to own them too. Self 
preservation is one of the strongest in- 

July 1, 1893. 



stincts of human nature. Can such a 
journal be made powerful, prosperous and 
popular without disturbing the interests 
of vested rights? 

It has been well known to those " be- 
hind the scenes " that the financial state 
of the Journal has of late been question- 
able; that in influence and importance it 
was ever becoming weaker and weaker, is 
evident to every one. 

It may have been in questionable taste 

for Dr. R. Harvey Reed to have '^let the 
cat out of the bag,'^ yet as a member of 
the Business Committee he was bound to 
inform the rank and file of the actual 
state of affairs. That there was no justi- 
fication for branding him ' ' a liar, a crank 
and a fool," because he told the truth and 
sounded the warning note, is evident by 
the action of the trustees in retiring the 
one who employed this intemperate and 
harsh language. 

m MEMORIUM.— JAMES McOANK, M. D., LL. D.— 1836-1893. 

Was born fifty- seven years ago in Penn 
Township, Allegheny County, Pa. His 
lather served under Anthony Wayne in 
the war for American Independence. In 
early boyhood he passed his summers 
working on his father's farm, and the 
winter months as a pupil of John G. 
Beatty, who taught him, in addition to 
the public school curriculum of that time, 
Latin and the higher mathematics. At 
about thirteen years of age his father died, 
when he began teaching school and became 
a leading member of a local debating soci- 
ety. Even at this early date he was a 
ready, fluent and earnest talker. Tiring 
of the monotony of country life, and like 
the majority of young men of his age, 
not knowing exactly what to do with him- 
self, he decided upon a mercantile career, 
and at the age of eighteen came to Pitts- 
burgh, where, after graduating at Dufl's 
College, he spent several years as book- 
keeper in a business house. This seden- 
tary life became irksome to him, his 
health was not good, and acting upon the 
Mvice of his physician, who regarded him 
as a young man of promising talents, he 
finally decided to study medicine. With 
this object in view, he, in 1858, entered 
the office of Drs. Thomas and John Dick- 
son, Sr. 

He graduated from the Medical Depart- 
ment of the University of Pennsylvania 
in 1863;, and immediately entered the 
medical service of the army as assistant- 
surgeon of the Fifth Penns^ylvania Volun- 
teers. He continued in this service until 
the close of the war, when he returned to 
Pittsburgh and began the practice of 

medicine with Dr. W. 0. Reiter. Two 
years later he received the appointment of 
surgeon to the Marine Hospital, and the 
connection with Dr. Reiter was soon after- 
ward dissolved. 

He was next appointed one of the sur- 
geons of the Western Pennsylvania Hos- 
pital, which position he held until a few 
months ago, when he resigned because of 
ill health, and accepted the appointment 
of consulting surgeon. For twenty years 
he has been one of the surgeons of the 
Pennsylvania, the Allegheny Valley, and 
other railroads entering this city. 

He was an active and influential mem- 
ber of the Pittsburgh Free Dispensary 
from its inception, of the Board of Health 
for many years, of the Allegheny County 
Medical "Society, of the State Medical So- 
ciety, of the American Medical Associa- 
tion, of the American Surgical Associa- 
tion and of the American Association of 
Obstetricians and Gynecologists, but 
owing to ill health he was never able to at- 
tend a session of the latter. 

In spite of the busy life he led, his 
ardent love and natural aptitude for teach- 
ing led him — in connection with his con- 
freres of the "Mott Medical Club"— to 
undertake the arduous task of organizing 
the first medical college in Western Penn- 
sylvania. Into this work he threw all his 
enthusiasm and devoted to it all his energy 
and influence. Caring but little for pecuniary 
reward it was with him a labor of love. 
In September, 1886, after years of weary 
and distasteful work, the culminating 
point of his ambition was attained by his 
election to the chair of Professor of the 



Vol. Ixix 

Principles and Practice of Surgery. This 
position, notwithstanding his failing 
health, and in defiance of bodily suffering, 
he filled until a few months prior to his 
death. At last, his physical endurance 
being exhausted, his grateful and sorrow- 
ing colleagues unanimously nominated 
him for appointment as " Emeritus Pro- 
fessor," a last tribute to his eminent 
worth and ability, but before this action 
could be confirmed by the board of trust- 
ees of the University, death had claimed 
him as his own. 

He died a martyr to his profession — a 
sacrifice upon the altar of charity. His 
love for it and devotion to it was the di- 
rect cause of his death. He performed 
an enormous amount of work, and it was 
in the performance of a surgiciil operation, 
a work of charity in the Western Pennsyl- 
vania Hospital, that he received the fatal 
shaft from the quiver of the fell destroyer. 
Had he, like many others, turned aside 
from charity work and devoted himself 
strictly to his lucrative clientele, he would 
be living to-day. 

He never ceased to be a student. He 
was too broad-minded to make a success- 
ful specialist. His mental attainm.ents 
were too great, his studies and reading too 
comprehensive, his ambition too high for 
any single department of his profession to 
permit free scope to his talents. His mind 
was alert to grasp and tenacious to retain 
knowledge, which enabled him to easily 
keep pace with progress and improvement, 
however rapid, in every department of 
medical science. 

He stood in the front rank of the lead- 
ers of the profession. His savoir faire, 
his strong personal individuality, his im- 
pulsive and generous nature won him a 
nost of friends inandout of the profession. 

His reputation and practice were not 
limited to his own city, county or State, 
but were national. His life was one of 
unceasing toil. There are but 'few surgi- 
cal operations that he had not performed. 
His profound knowledge, rather than his 
personal magnetism, made him popular 
with all the members of the profession 
with whom he came in contact, making 
him eagerly sought as a consultant, and 
he never betrayed this trust. 

He followed, as strictly as the present 
state of society will, perhaps, admit, the 
axiom, "a physician's first duty is to his 
patient, his second only to himself." 

He was in the active practice of his 
profession from 1863 to 1893 — a period 
of but thirty years, yet in those thirty, 
years he accomplished, perhaps, a task as 
great, and fulfilled a destiny as rounded 
and complete as the average practitioner 
of fifty years standing. A man's life is 
measured by his works. Judged from this 
standpoint, although he was but fifty- 
seven years of age, his death was not pre- 

He had faults, but no vices, and his 
virtues were too many to dwell upon at 
greater length. By his death his wife 
loses a loving husband, his children an 
affectionate father, his colleagues a genial 
companion and true friend, and his pro- 
fession a devoted follower. Requiescat in 

W. Sniyely, 
J. B. Murdoch, 
0. B. KiKG, 
Committee of Faculty, 
Western Fenn'a Medical College. 
Pittsburgh, June 19, 1893. 

Morphine and Gastric Secretion. 

Hitzig has noted that morphine admin- 
istered hypodermicly to a dog is shortly 
afterward excreted by the stomach, and 
that, following upon this, there is a marked 
reduction in the amount of gastric juice 
secreted, and more especially of its acid 
constitutant. The cessation of the action 
of the drug is followed by the secretion of 
excess of hydrochloric acid. With regard 
to the effect upon human gastric juice, the 
case is described of a patient who con- 
sumed daily two grammes each of mor- 
phine and cocaine, the latter having been 
resorted to in an endeavor to remove the 
craving for the morphine. He was treated 
by gradual reduction of the doses of the 
alkaloids, but it was not until the mor- 
phine was entirely discontinued that the 
presence of free hydrochloric acid was in- 
dicated {Neur. Centr.^ B. M. J. Epit., 

^'What did de doctah say ailed yer 
mostly, Bill ? " '' He 'lowed dat I ,had a 
conflagration of diseases. Fust, de salva- 
tion glands don't insist my indigestion ; dat 
makes a torpedo liver, cose I'm liable to go 
off any minute." 

July 1, 1893. 




In" the Repoktek, of May 27th, 
appears the annual address of Dr. John 
B. Roberts, President of Philadelphia Co. 
Medical Society, entitled "Points of 
Similarity between us and Homoeopathic 
Physicians. ^^ President Roberts deserves 
thanks, and thanks Avith a big T, for the 
able manner in which he has handled the 
subject regardless of the title; it is a 
masterly exhibition, or even expose, of 
the position of the Sectarian Brethren as 
they are today. For the charming schol- 
arly style in which the subject "is done,'^ 
the Doctor " takes the cake," and deserves 
the whole bakery. Dr. Roberts might 
have gone still farther in his investiga- 
tions and told "us'^ of "the Points of 
Similarity," at the starting point, between 
"us and Homoeopathic Physicians." 

For instance, regardless of his choice of 
school, the average student starts in with 
very little general information about 
"men and things,^' and none whatever, 
of the subject of his choice. He steps 
into the field, not to investigate but to 
follow a beaten path, and is ready to 
believe all that is taught him. If he 
chooses a Homceopathic School, he is ready 
to believe that " Regulars," styled " Allo- 
pathists/' are little short of antiquated, 
dough-headed murderers, who treat pa- 
tients according to the rhyme : 

"I purges, I pukes, and I sweats them, 
Then if they die, I lets them." 

He is ready to believe that in accordance 
with "SimiliaSimilibus Curantur" theory 
the administration of gold will cause a 
man to be avaricious, and the administra- 
tion of sulphur cause a man to despair of 
his eternal salvation, and even long for the 
"Lake of Fire and Brimstone," if given 
in suificient doses ; while the proper atten- 
uation of the same will chase out the des- 
pair and raise a camp meeting feeling in 
his bosom. If he sups with the "Eclec- 
tics," he has no difficulty in swallowing 
the " Pap" that both Regulars (here also 
styled Allopathists) and Homoeopaths, are 
following a metallic route to perdition, and 
that Eclectics alone " select " their reme- 
dies from all proper sources. If he goes 

to the "Regulars," he is fully capable of 
taking in, without an effort, the doctrines 
that Homoeopaths and Eclectics are "Igno- 
rant Heretics," to be classed with " Quacks 
and Tramps." Just in accordance with 
the class of Professors he falls in with, 
will he be filled up, more or less, with the 
gall and bitterness of adverse criticism. 
So he goes out into the world, armed, he 
thinks, against both disease and profes- 
sional foe. The world into which he goes, 
knowing just as little of the science of 
medicine as he did a few months ago^ 
hears his ranting and raving, breaks into 
factions, and believes or disbelieves, some 
from ignorance, and some from pure cus- 

Another " point of similarity" the 
Doctor might have mentioned is the 
ignorance of the average practitioner of 
either school of what is taught in the 
adverse school. Now, as the value of. 
one's opinion, on a given subject, is just 
in accordance with the perfectness of one's 
knowledge of the subject, it follows that 
most of the time neither party knows 
what they are talking about. Hence, it 
becomes a sort of "You're a liar" and 
"You're another" kind of an argument, 
while the outsider looks on and grins. In 
view of all this. Dr. Robert's paper is 
most timely; it shows that the Homoeo- 
pathic people are coming around to 
rational medicine because it is rational. 
He shows that a few, only a few, play 
Hahnemann, with Hahnemann as the 
principal character. That many, very 
many, are content with only a recoguition 
of him as "a has been." The picture is 
as bad as the "play of Hamlet, with 
Hamlet left out," and content that the 
ghost of his Father is left in. 

The Doctor^s "investigation" is in- 
tended by him to illustrate his position, 
that membership in a regular medical 
society ought to be open to this class of 
physicians. He accords, and justly so, to 
them "courtesy, refinement and large 
hearted charity." In a communication of 
mine, published in The Repoetee of 
February 23rd, 1889, I used these words: 
" We must recognize that there are just 



Vol. Ixix 

as true gentlemen, loyal citizens and 
Christians practicing in the other schools 
as in our own/" We can all, at least, re- 
spect the Sectarian, who is honestly 
practicing his belief, just as one can re- 
spect a fellow regular whose idea of treat- 
ment may differ radically from one's own. 
Unless, indeed, it is that class, few in 
number I am glad to say, who still calling 
themselves ^' regular," assume the, — 
"Treat you either way" dodge. A sort 
of — ^' you pays your money and takes 
your choice " — game of therapeutics. No 
one respects them, though sometimes 
they are of more than average ability. 
One of the brainiest practitioners, of my 
knowledge, in Western Pennsylvania, 
does all that, and more too, for he poses 
thusly: " Catharsis, Allopathic, Emesis, 
Homoeopathic, see ? so I use a double 
system, one acting well, upwards, the 
other acting well, downwards, result, 
perfection, see ? " Of course, the patient 
sees, they always do, when that sort of 
thing is done impressively, and the double 
system doctor pockets good fees. I don't 
think Dr. Koberts would care about him, 
. though, in a " regular" way. 

While I do not intend this as an illustra- 
tion of the class of physicians President 
Eoberts presents in his paper, yet I do say 
that this paper causes one to reflect, thought- 
fully reflect, on his facts and suggestion 
in this way, viz : " Is it honest to cure 
diseases by non-Homoeopathic methods 
and contrary to Homoeopathic law, and 
yet claim Homoeopathic credit for the re- 
sult f Is it honest to admit that ^ ' had 
not our school drifted away from the 
practice of forty years ago, it would have 
been dead and buried long since," and yet 
give that same law of cure of forty years 
ago, the credit of what that school does 
by rational methods and regular school 
therapeutics to-day ? Is it honest for a 
school that uses as "Text Books — the 
U. S. P. — Woods Therapeutics — Pepper's 
System of Medicine," as well as those by 
" Cross, Agnew, Playfair, etc.," to be 
posing as teaching according to Homoeo- 
pathic law ? " Pepper " recommended as 
a " Text Book " by " Hahneman College" 
is enough to cause the shade of the 
Apostle of Homoeopathy to shed bitter 
tears, even though the " Pepper" wasn't 
re{a)d. That somewhat salty sentence 
rolled out from my pen before I really 
caught on to it myself, and it wasn't in- 

tended as a dry joke either. Is it honest 
for a school to use the brains, scholarship 
and text books of rational medicine, and 
at the same time refuse to sit on an 
Examining Board with that scholarship 
and examine on those text books ? Use the 
books for the student, and yet insist on 
examination according to Homoeopathic 
Law. Is it honest? If it is, then my 
very good friend Dr. Eoberts is right, and 
we should open the doors of our societies 
and bid them enter. If it is not honest 
to forsake the substance and claim credit 
for the shadow; if it is not honest to 
forsake Homoeopathic Law, while claiming 
credit for " Similia Similibus Curantur" 
(as every one who still clings to the name 
does) then the door should be shut. There 
is no doubt but that a very large portion 
of the regular profession are willing to sit 
down and exchange, gladly, specimens with 
Homoeopathic physicians where sectarian- 
ism is by them set aside. Is it not asking 
too much to throw open the doors of 
rational medical recognition to gentlemen 
who while ''' practicing it, deny the faith. ''^ 
Dr. Koberts is such a genial, good hearted 
man, to say nothing of his sterling pro- 
fessional qualities, that the Homoeopathist 
who would not want to consult with him 
would be "hard-hearted and white-livered'' 
indeed, and the doctor is just enough and 
broad enough to be willing to help even a 
" Thompsonian " to improve his "number 
six." However, would it not be as well 
to wait until the gentlemen of " Similar 
Points " get to the broad "Similar Point" 
that Dr. Eoberts has reached, and want 
to come in. I am sure that they can, 
just as soon as they reach a " Similar 
Point" of being not sectarian, but 
Fellow Craftsmen for the common good. 
In the meantime I think the position of 
the regular prof ession towards Dr. Eoberts' 
paper will be this " That we thank him 
for the publication, for its information 
and general blessedness, regardless of his 

S. S. TowLEE, M.D., 

Marienville, Pa. 

Purulent Cystitis. 

lodoformi pulv., 
Mucilag. acacise, 
Glycerini puri, 
Aquas destill.— M. 

-After washing- out the bladder about five drachms 
combination is injected and aUowed to remain 


of thi 
for fifteen minutes. 

July 1, 1893. 

Library Table. 



A Standard Dictionary of English Language. Funk 
& Wagnalls Co., IS and 20 Astor Place, New York. 

We have examined the sample pages of the 
"Standard Dictionary" and are convinced 
that the work will prove of invaluable ser- 
vice, and will take a place in the highest 
ranks of works of the kind. It contains the 
best points of most other similar works with 
some distinguishing features of its own of 
greatest value. Among them, we note first 
that the etymology of words is placed after 
the definition, that in the definition of words 
the most common meaning is given first, 
which is the order of practical common 
sense. That in the pronunciation of words, 
the scientific alphabet recommended by the 
American Philological Association is used. 
That the quotations used to verify or illus- 
trate the meaning of words are located by 
author, book, page and edition. That dis- 
puted pronunciations and the spellings are 
so given as to furnish a consensus of the best 
judgment of the English speaking world on 
all disputed words. That a serious and suc- 
cessful attempt has been made to reduce to a 
system the compounding words. That obso- 
lete, foreign, dialetic slang words are given 
places only to be sought for in a general 
English dictionary, while the vocabulary is 
extraordinarily rich and full, surpassing any 
other dictionary. 

A marked feature is the pictorial illustra- 
tions, nearly 5000 in number, including 
several full page groups in colors made in 
the highest style of the art by the Messrs. 

We note the editorial stafl" comprises a 
number of the most eminent specialists in 
their various departments, and their work 
seems to be extraordinarily well done. For 
instance, in all matter pertaining to our medi- 
cal profession, the dictionary is full, accurate, 
and up to date. The features of this 
dictionary will commend it to students and 
scholars. The work will prove of superior 
convenience and includes an extraordinary 
amount of material not found in the 
ordinary dictionary, and will quickly become 
the " standard " in reality as well as in name. 

The Surgery and Surgical Anatomy of the Ear. By 
Albert H. Tuttle, M. D. Physicians Leisure Library, 
Geo. S. Davis, Detroit, Mich., 1893. 

Works like this one should be of immense 
value to the busy surgeon, as it furnishes in a 
reliable and compact manner, the topograph- 
ical landmarks of the temporal bone after 
giving us five chapters, four of them clearly 
describin'g the surgical treatment of the ear, 
beginning with the external canal and con- 
cluding with the brain lesions so often result- 
ing from diseases of the middle ear. The 
first chapter is devoted to the anatomy of 
the ear. In describing the diseases of the ex- 
ternal canal, the author does not mention 

atresia of the canal, a condition by no means 
rare and calling for surgical intervention. 
He very wisely considers suppurative inflam- 
mations of the brain and its meninges, ex- 
cept those of tuberculous or traumatic origin, 
to be associated with middle ear disease. In 
the chapter on the mastoid and its opera- 
tions, the author considers Schwertze's indi- 
cations, eight in number, as the most valua- 
ble in determining the advisability of an 
operation; early operation is advised in all 
cases as tending to lessen the inflammatory 
process and rarelj^ terminating fatally if 
early performed. Dr. Tuttle also furnishes a 
ready means of refering to the literature of 
many authors on the anatomy and surgical 
treatment of the ear. 

The scholarly presentation of this little 
work should make it welcomed both by the 
general surgeon and aurist; it is, however, for 
its sections of the temporal bone and topo- 
graphical description that Dr. Tuttle has 
furnished us so reliable a guide. It may be 
said of this little w^ork, that it embodies in a 
condensed form a large part of the most re- 
cent contributions on the surgery of the ear. 

The Diseases of the Nervous System. By Dr. Ludwig 
Hirt, Professor at the University of Breslau. Trans- 
lated with pernaission of the author by August 
Hoch, M.D.; assisted by Frank R. Smith, A M. 
(cantab), M.D., with an introduction by William 
Osier, M.D., F.R.C.P., Professor of Medicine in the 
Johns Hopkins University, etc. With 178 illus- 
trations. Pp. 683., New York : D. Appleton & Co., 

In his "Introductory Note" to this English 
translation of Professor Hirt's valuable work, 
Dr. Osier informs us that the idea of having 
it translated was due to Dr. Weir Mitchell 
calling his attention to its exceptionally good 
arrangement and thorough description oi 
the nervous system, and all who read this 
translation must duly appreciate the appear- 
ance of another work which manifests so 
large an amount of research and personal 
observation in this class of diseases. 

The book has three principal divisions: 
(1) Diseases of the Brain and its Meninges, 
including those of the Cranial Nerves. (2) 
Diseases of the Spinal Cord, and (3) Diseases 
of the General System. 

After treating of diseases of the meninges 
of the brain, no less than 128 pages are de- 
voted to a lucid and comprehensive descrip- 
tion of the diseases of the cranial nerves. 
The author does not discuss one here, one 
there, and the peripheral nerves of the spinal 
cord partly in one place, partly in another, 
according as he is dealing with their motor 
or their sensory disturbances, but he speaks 
of the former and of the latter in the order 
that their anatomical position would indi- 

A somewhat novel arrangement of the 
subjects dealt with has been adopted. For 
instance, tabes dorsalis and dementia 
paralytica are placed among the diseases ot 


Current Literature. 

Vol. Ixix 

the general nervous system, instead of in 
the sections on diseases of the cord and dis- 
eases of the brain respectively. As Dr. 
Osier justly remarks " the fact which makes 
the work of value to the teacher, the student, 
and the practitioner is the graphic descrip- 
tion of the anatomy and symptomatology 
of the different diseases. Where all is so 
good it is invidious to select, but the chapter 
on tabes is an illustration of our author's 
lucid and, at the same time, thorough treat- 
ment of his subject." Whilst believing that 
it is possible to cure tabes of lentic origin, he 
concludes the question of prognosis by say- 
ing " On the whole, one can say that out of 
250 tabetics one has a chance of regaining 
his previous health." 

As to therapeutics, he considers that al- 
though syphilis is at the bottom of many in- 
stances of tabes, an anti-syphilitic treatment 
is only admissable in a very small number of 
cases. Of internal remedies, silver nitrate, 
ergotin and physostigmine have the prefer- 
ence, in addition to which electrical treat- 
ment may yield excellent results in recent 
cases. He speaks most favorably of the ex- 
cellent general faradization advised by Beard 
and Rockwell, and the faradic brush applied 
to the back as recommended by Rumpf. 

In a large number of cases the cold water 
treatment has been found extremely benefi- 
cial, but he emphatically w^arns the practi- 
tioner against the use of warm or hot, as well 
as steam and sweat baths. The results of 
massage, he says, are not satisfactory and in 
relating his experience of the " Suspension " 
treatment of 115 patients, he states that in no 
single instance was he able to note any 
marked or lasting improvement, and the im- 
pression which he himself has gathered is, 
that "suspension" will be in vogue for a 
time, only to fall again into complete ob- 
livion. The same candid spirit pervades the 
expression of opinion as to the use of reme- 
dies in other diseases of the nervous system. 
The treatment of myxoedema is omitted, this 
apparent omission is probably due to the 
fact that the original work is now four years 

The excellent illustrations, w^hich are m.ost 
of them new, faithfully elucidate the text 
and greatly add to the attractiveness of the 
work. We regret that our space will not 

permit us to dwell further upon its contents, 
but we confidently recommend it to the prac- 
titioner as a faithful guide in the study and 
treatment of nervous diseases. 

3Iateria Medica and Therapeutics. In two vols. By 
.Tno, V. Shoemaker. The F. A. Davis Co., Pub- 

Of books on therapeutics there seems to be 
no end. A book that meets a want or fills a 
place in medical literature should either say 
something that others do not say, or should 
say she oft repeated in much better styyje 
than has been done by anyone else. This 
work does neither, therefore, it does not fill 
a long felt want. If we did not have two or 
three very excellent works on this subject, 
Shoemaker's book might be hailed as a valu- 
able tontribution. But the market is glutted 
with two very able English works and two 
most excellent American ones. It is true 
this work is not without some excellent 
points; yet it blemishes far outnumber its 
good qualities- 

The great value and importance of the im- 
ponderable agents such as heat, electricity, 
hypnotism, massage, rest and the like are 
very ably, fully and clearly set forth in the 
first volume, and if the auther had stopped 
with the first volume his work would have 
been both unique and useful. The second 
volume is taken up with drugs and their 

Due attention is given to the new remedise 
such as the coal tar preparations. Animal 
extracts are not even ignored. For this Dr. 
Shoemaker deserves great credit, but in the 
discription and application of the more 
familiar remedies there is too much accepted 
from others and too little of the author's own 
experience to give an air of authority to 
what is said. When antipyrine is recommen- 
ded for typhoid fever, one is prone to look 
upon the work as an unsafe guide to the in- 

For the beginner, the work is not practical 
enough, and for the experienced and scien- 
tific physician there are other books that are 
much better for his library or office table. It 
might pay any one to purchase the first 
volume, but the second one would last a long 
time in the hands of even the most 
omnivorous reader. 



for June. Dr. Paul F. Munde contributes an 
article on 

Abdomino^pelvic Fistula after Celiotomy and 
Laparotomy ; its Prevention and Treat= 

The author comes to the following conclu- 
sions : 

1. The formation and persistence of ab- 
domino-pelvic sinuses after celiotomy and 

laparotomy should be prevented by all the 
means at our disposal. 

2. Such sinuses cannot always be prevented, 
no matter how careful we are. 

3. A certain number of early, moderate 
cases may heal under appropriate treatment, 
and even a few old cases may recover after 

4. Celiotomy, or the opening of the ab- 
dominal cavity, is usually not necessary or 
beneficial in treating these sinuses, unless it 

July 1, 1893. 

Current Literature. 


can be distinctly shown or suspected with 
good reason that the focus of suppuration 
can be reached only in that way. 

5. Through drainage into the vagina, 
whenever practicable, forms the best method 
of curing deep sinuses. 

6. In some cases, where the other methods, 
medical and surgical, have failed, and where 
Che general health is fail' and the sinus gives 
but little inconvenience, it is justifiable not 
to subject the patient to the risks and un- 
certainty of an abdominal section (celiotomy), 
but to advise her to " let well enough alone" 
and keep her sinus so long as she can live 
comfortable with it. 

Dr. Andrew F. Currier contributes a paper 
on "Septicemia and its Treatment with 
Oxygen." The author reports two cases, in 
one of which it was believed that the oxygen 
repeatedly warded off impending death. In 
the second case, while it is believed the 
oxygen delayed the fatal issue, it was power- 
less to overcome the advancing sepsis. The 
only ill effect which the author has ever seen 
in its use, consists in pain referred to the 
region of the stomach, probably due to 
swallowing the oxygen, which may have 
been administered under too great pressure. 

Dr. Charles J. Cullingworth discusses the 
subject of 

Retention of Menstrual Fluid, in Cases of 
Bicorned Uterus, from Uni=lateral Atresia 
of Uterus or Vagina. 

The author reports a case where the tumor 
was thought to be a suppurating cyst outside 
the uterus and a section undertaken for its 
removal. At the operation, the true con- 
dition was discovered and the. retained fluid 
evacuated per vaginam. The author states 
that it would have been impossible to have 
arrived at a correct diagnosis without ab- 
dominal exploration. The two great dangers 
of the vaginal evacuation of the retained 
fluid are septicemia and the rupture of a 
distended Fallopian tube. Both dangers can 
be overcome, the former by strict antisepsis, 
and the latter by slow evacuation of the 
accumulated blood, so as to minimize the 
risk of exciting reflex muscular contractions. 
In the event of a rupture of a tube, the ab- 
domen should be promptly opened, the peri- 
toneal cavity cleansed, and the ruptured tube 
removed. The report includes a number of 
similar cases reported by other observers, and 
is illustrated by a cut representing the mal- 
formation described in the paper. 
Dr. H. J. Boldt discusses 

The Operative Treatment for nyo=f ibromata 
of the Uterus. 

He states that he has been unable by means 
of electricity, to diminish the size of the 
tumor in any case, though in a number of in- 
stances the symptoms caused by the growth 
have been relieved — that is the pain and 
hemorrhage; in others again, the treatment 
was not only negative, but the patients grad- 
ually became worse. He would however, 
sanction operation in cases of ordinary inter- 
stital growths, only after the current had 
been tried. He warns against the danger of 
producing suppuration in the tumor hj 
means of the current. If a myomatous 

uterus in small enough to be removed per 
vaginam in toto, vaginal hysterectomy then 
is the operation of choice, provided other 
measures fail of relief. If an abdominal 
operation is necessary, the neoplasm should 
be removed by enucleation, when possible, 
the bed being sewn up with buried catgut 
sutures. Constricting the cervix with an 
elastic suture during (enucleation he regards 
as bad. When the body of the uterus must 
be removed along with the tumor, no method 
of treating the stump has given as good 
results as the extra-peritoneal. Personally 
however, he favors the intra-peritoneal 
method, and regards Martin's method as 
ideal. He uses nothing but catgut for the 
suturing and tying, except in closing the ab- 
dominal incision. In the intra-peritoneal 
treatment, secondary hemorrhage plays an 
important role in causing death. This need 
not be feared if the ligatures are properly 
placed in complete hysterectomy. The main 
cause of death in complete hysterectomy is 
shock or extreme anemia, and for that reason 
he has not entirely given up the extra-peri- 
toneal treatment. The paper gives the re- 
port of twenty-one cases operated upon. 
Dr. R. Stansbury Sutton discusses the 

Elastic Ligature in Supra=vaginal Hysterec= 

The author prefers the extra-peritoneal 
treatment of the stump because statistics 
show that this is the better method. The 
author regards rubber as the ideal substance 
for the composition of the constrictor for the 
compression of such tissue as the cervix. 
He has abandoned the wire noeud on account 
of the danger from hemorrhage unless the 
wire is constantly watched and tightened. 
The rubber constrictor is turned twice about 
the cervix, underneath the transfixing pin, 
secured by a double knot, behind which a 
heavy silk ligature has been securely tied, 
and closely in front of which a pair of lock- 
handled forceps grasps the free ends of the 
ligature. This method is safe against hemor- 
rhage under all circumstances. There is no 
depending upon an assistant, nurse or self to 
tighten the ligature; it follows up the shrink- 
ing pedicle painlessly and effectually. The 
primary dressing may remain on the pedicle 
from nine to thirteen days without any dis- 
turbance whatever. During the three years 
in which he has used this ligature, he has not 
found a single objection to it, and his hyster- 
ectomies have given him no more trouble 
than his ovariotomies. The paper is illus- 
trated with cuts showing the method of 
applying the ligature. 

Dr. Howard A. Kelly describes what he 
considers to be the "Best Needle Holder," 
giving a cut of the instrument described. 

Dr. Henry C. Coe discusses the "Internal 
Migration of the Ovum," reporting a case of 
repeated ectopic gestation possibly support- 
ing the theory. The paper is illustrated with 
a cut showing the conditions described in the 

This issue also contains the address of Pro- 
fessor Theophilus Parvin to the American 
Gynecological Association, in which the 
author urges the necessity of the chairs of 


Current Literature, 

Vol. Ixix 

gynecology and obstetrics in our colleges 
being filled by one man and not divided as is 
the usual custom. This number concludes 
with a memorial notice of the late Dr. 
Charles Carroll Lee. 


for June. Dr. Frederick P. Henry contrib- 
utes a paper on the 

Treatment of Pulmonary Tuberculosis. 

Cod liver oil is given the first rank in the 
remedies advised by the author. Cod liver 
oil cannot be retained, or if retained is of very 
little value, in the cases with febrile symp- 
toms. In such cases, he advises the use of 
morrhuol. Another drug that is useful is ar- 
senic. Alcohol he considers of doubtful 
value, though it is possible that, in modera- 
tion, it may favor the cicatrization of tuber- 
cular deposits in cavities. He is of the 
opinion that the hypophosphites of soda and 
lime possess no advantage over the phos- 
phates, as they probably undergo oxidation 
in the stomach. Glycerin may be prescribed 
in place of cod liver oil to those with whom 
the oil does not agree. Iron is advised for 
the anaemia that so constantly accompanies 
phthisis,* but the author thinks that it is of 
no use when there is febrile movement. In 
afebrile cases, it may assist greatly in main- 
taining the general state of nutrition. For 
the cough, he considers hydrocyanic acid to 
be one of the best drugs and, when this alone 
will not sufiice, a little morphia may be 
added. Iodine, carbolic acid and creasote, 
by inhalation, are of service in allaying the 
cough, as is also the well known solution of 
Dobell. For haemoptysis, the drugs on 
which most reliance is to be placed are ergot, 
sulphuric and gallic acids. The old-fash- 
ioned remedy of salt he has also found use- 
ful. Dry cupping of the aflfected side and 
hot foot-baths are useful as derivatives, and, 
if the bowels are constipated, a purgative 
should be administered. Night-sweats are 
controlled by means of atropia. He has used 
picrotoxin, though of late he has used agarcin 
with much benefit and speaks highly of it. 
It should be given in doses of one-tenth of a 
grain, combined with a grain or two of 
Dover's powder. 

Dr. M. B. Ward, in an article on " Pyome- 
tra," reports a casein which operation was re- 
fused by the patient till in extremis. At the 
section the uterus was found to be completely 
necrosed, with the walls as ,thin as paper. 
Total extirpation of the uterus was performed 
but the patient died. Hysterectomy he re- 
gards as the only treatment for the condition. 

Dr. Edward A. Lee, in an article entitled 
"Preventive Treatment after exposure to 
Gonorrhoea; and Treatment of the Disease," 
advocates the irrigation of the urethra for 
two or three minutes at a time, and repeated 
once or twice, with a bichloride solution of 
1-10,000, or 1-20,000. At the same time, the 
glans-penis, prepuce and body of the organ 
should be bathed in the same solution, or one 
of 1-6,000 or 1-8,000. This, he states, will 
prevent many cases from developing, pro- 
vided they be seen within a few hours after 

exposure. After the disease has been in 
progress for two or three days, he prescribes 
salines and copaiba, internally, with injec- 
tions of bichloride 1-10,000 or 1-20,000 re- 
peated three times a day and followed im- 
mediately by the injection of a solution of 
sulphate of zinc with bismuth. 

Dr. J. F. Binnie contributes a paper on 
'■'■ Gradual Auto-inoculation as a Factor in 
the Production of Immunity from the Effects 
of Septic Infection." 

Dr. Emory Lanphear reports a " Case of 
Sacro-iliac Disease with Immense Distention 
of the Abdomen with Pus— Laparotomy— 
Cure." The remaining articles in this issue : 
" A Methods of Operating Aboux the Face by 
which but Little Blood Enters the Mouth," 
by Dr. W. W. Keen; "Amputation at the 
Hip-Joint — Tumor Near the Sub-clavian Ves- 
sels — Operation on the Fifth Nerve," by Dr. 
John B. Deaver; " Metatarsalgia (Morton's 
Painful AfiTection of the Foot)," by Dr. 
S. K. Morton; were read at the meeting of 
the Philadelphia Academy of Surgery on 
March 6th, 1893, and appeared in the Medi- 
cal AND Surgical Reporter for May 13th, 


American EIectro=Therapeutic Association. 

The third annual meeting of the American 
Electro-Therapeutic Association will be held 
in Chicago, September 12, 13 and 14, at 
Appollo Hall, Central Music Hall Block. 

Members of the medical profession inter- 
ested in Electro-Therapeutics are cordially 
invited to attend. 

Austin H. Goelet, M.D., Pres. 
Margaret A. Ceeaves, M.D., Secy. 


U. S. ARMY FROM JUNE 17, 1893, TO JUNE 24, 


An army retiring board having found 
Major JohnO. Skinner,Surgeon, incapacitated 
for active service, the extension of leave of 
absence on Surgeon's certificate of disability, 
is further extended until further orders. 

Leave of absence for two months, to take 
effect on or about July 15, 1893, is granted 
1st Lieutenant Benjamin Brooke, Assistant 
Surgeon, U. S. Army. 

Leave of absence for one month and twelve 
days, from August 1, 1893, is granted Captain 
Charles E. Woodruff, Assistant Surgeon. 

1st Lieutenant Harry M. Hallock, Assis- 
tant Surgeon will, on July 6, 1893, proceed to 
Griffin, Georgia, and report to Captain- 
George G. Greenough, 4th Artillery, for duty 
in connection with the encampment of State 
troops at that place. 

1st Lieutenant, J. D. Glennan, Assistant 
Surgeon, now at Fort Mcintosh, Texas, will 
report to the commanding officer 3rd Cavalry, 
to accompany Troop I of the reginaent to 
Fort Sill, O. T. 

Vol. LXIX, No. 2. 
Whole No. 1897. 

JULY 8, 1893 

mS.OO per Annum 
10 Cents a Copy 



Established 1853, by S. W. Butler. M^D, 



Entered as Second-Class Matter at Philadelphia P. O. 

P. O. BOX 843, PHILA, PA, 


Paul Hilbert. 
The Palpable and Movable Kidneys. 


Dr. George M. Lefferts. 
Quinsy or Peri-Tonsillar Abscess and Acute Follicu- 
lar Tonsillitis; their Differential Diagnosis and 
Treatment 41 


Ernest Hart, London. 
Cholera. 45 

Mary Sherwood, M. D. , Baltimore, Md. 
Ovariotomy on Patients over Seventy, by American 
Operators 50 


American Medical Association 52 


Preventive Medicine. gg 




Hints to Prevent the Spread of Consumption. . . 73 






Galenical Preparations 


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-Pi Aseafoetida . . . 2 gr. | Ac. Arsenious . . 1-30 gr. 
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Medical and Surgical 

No. 1897. 


Vol. LXIX— No. 2 




During the year 1889, Israel called atten- 
tion to palpation of healthy and diseased 
kindeys, placing stress upon those methods 
which give definite ideas about the size, 
the form, and position of the kidneys un- 
der normal or. abnormal conditions. Pal- 
pation of the kidneys is performed with 
both hands, the patient either standing, 
lying on the back, side or knee-elbow po- 
sition. As a rule, the back is preferred by 
both patient and doctor. In palpating 
the right kidney, the physician stands to 
the right of the patient, the left hand un- 
der the loins immediately behind the last 
rib, while the right hand, placed opposite 
the anterior surface, exerts a gradually 
increasing pressure. In this manner the 
organ is frequently brought between the 
fingers of both hands. If this method 
cannot be carried out successfully, the ex- 
amination on the side is the next prefer- 
able, or the patient may be examined 
standing, the body slightly bent [for- 

Israel has concluded from his studies 
that every kidney can be partially or en- 
tirely palpated, and recognizes a motion 
induced on the normal kidney by the res- 
piratory movements. 

Kuttner, under the direction of Ewald, 
in the polyclinic of the Augusta Hospital, 
of Berlin, made a careful study of this 
subject and, in the course of eight 

*A lecture read before the Society of Wissenschaft- 
litche Heil in Konigsburg i. Pr. Translated by M, B. 
Weruee, M. D. 

months, had collected one hundred cases 
in which the kidneys could be palpated. 
In opposition to Israel, Kuttner maintains 
that every kidney which shows in palpa- 
tion a tendency to motion during respira- 
tion should be regarded as pathological. 
In order to aid in deciding this question, 
the author has made a careful study of 
one hundred cases, giving a table which 
represents the grade of mobility, and if 
right, left or both were affected. He de- 
fines the three grades of mobility as follows : 
First grade of mobility : the lower portion 
of the kidney can be felt to about its mid- 
dle. This he names renpalpabilis. 

Second grade of mobility: the entire 
kidney can be felt between the fingers, 
known as ren mobilis. 

Third grade of mobility: the entire 
kidney can be felt and pushed upwards at 
will, and he names this ren migrans. 

This classification may lead the reader 
to think that the author regards the float- 
ing kidney, or ren migrans, as the highest 
grade of movable kidney, which, with 
truth, may be accepted, not, however, in 
the sense of Litten, who believes that the 
floating kidney is always of congenital ori- 
gin ; this view has never been demonstrat- 
ed with certainty, either clinically or ana- 

It is a well-known fact that movable 
kidneys occur more rarely in men than in 
women; this is also true of the first grade 
in the classification. In order to prove 
this, the author states that he served for 


Original Articles. 

Vol. Ixix 

more than a year in the polyclinic on the 
male side and found but few cases of pal- 
pable kidney. 

The hundred cases which I have col- 
lected have chiefly occurred among women. 
The frequency in which palpable kidneys 
can be found among women is shown by 
the fact that the first fifty cases were seen 
during the space of two months (May 28 
to July 28, 1890) ; during this time 435 
women were treated at the Polyclinic. 
The author was able to examine but half 
the number, say about 200 to 250, which 
has led him to conclude that palpable kid- 
neys among women stands as 1 to 5. 

The recognition of the first classifica- 
tion, reus palpabilis, can be aided by in- 
ducing the patient to take deep respira- 
tions. During inspiration the kidney us- 
ually descends and then can be easily felt 
by the examining hand^ while during the 
act of expiration it ascends beyond reach. 
This mobility during respiration of a nor- 
mal kidney the author has felt distinc- 
tively 95 times, twice in a lesser degree 
and three times it was impossible to feel 
it. He, for that reason, is inclined to be- 
lieve with Israel that the respiratory 
movement of the kidney is physiological 
and not, as Kuttner insists it to be, path- 

In the 100 cases examined, 65 were 
found of the right kidney, and 35 cases in 
which both kidneys were palpable. Forty 
of the 65 belong to the first grade, 25 to 
the second grade. The first grade of mo- 
bility was found in both kidneys 8 times, 
and 9 times of the second grade. In 17 
cases the entire right kidney could be felt, 
while the lower portion of the left could 
be barely outlined . There was but one 
true case of fioating kidney among the 
hundred. In this patient the left kidney 
was easily palpable. 

In all these cases there were none found 
in which the left kidney was alone dis- 

The author has added a table in which 
he has particularly studied the age of the 
patient and the three classifications. This 
table states that in patients between the 
years of 20 to 40 the kidneys are most 
easily palpable; that they occur most 
among women who have never been preg- 
nant. These statements coincide with 
those of Kuttner. In all cases an exam- 
ination of the uriue for albumen gave 
the following results : in 9 cases there 

was but small amount of albumen pres- 
ent; in 5 larger amount. This makes 
about 14 per cent, of the cases which con- 
tain albumen, and in comparing with other 
patients at the Polyclinic suifering from 
other diseases than that of the kidney, 
the author drew the following conclusions : 
That abnormal motility of the kidney 
will produce pathological changes and se- 
cretion of urine which may lead to albu- 

One patient with ren mobilisof the right 
side and ren palpabilis of the left side pre- 
sented,aside from the symptoms of acute ne- 
phritis and large quantities of albumen in 
in the urine, cylindrical casts and blood. 
The author was unable to find any changes 
in the form or consistence of the kidneys 
after the patient's recovery, such as have 
been observed by Litten and Israel. The 
author cannot add anything nQw to the 
causes which can lead to greater mobility 
of the kidney. Eepeated pregnancies can 
only, in his estimation, produce as much 
influence as Landau assumes. Frequently 
carrying heavy loads or curvature of the 
spine has been regarded as a cause for 
dislocation of the kidneys. - 

The author found in 8 cases a descent 
of the lower anterior border of the right 
lung; the same existed of the liver in 4 ; 
inguinal hernia in 2 ; prolapsus of the va- 
ginal walls once. In three women it was 
possible for him to locate by palpation 
both kidneys, liver and spleen, although 
there was no enlargement of any of the 
above-named organs. In two of these he 
found, in addition, a large prolapsed sto- 
mach reaching below the umbilicus. These 
cases maybe classed, in all probability, with 
those described by Glenard under the name 
of Enteroptose. 

Bartels and Muller-Warnick have de- 
scribed the connection between movable 
kidneys and diseases of the stomach; ex- 
plaining their theory that by traction of 
the movable kidney, a compression of the 
duodenum, and through this dilatation of 
the stomach. Litten has explained it in 
the opposite, declaring that the dilatation 
of the stomach is the primary affection, 
while the dislocation of the kidney be- 
comes secondary. These theories have, 
however, become questionable, and Litten 
has forsaken his theory entirely. Kittner, 
on the other hand, has called attention to 
the frequency of the presence of enlarged 
and displaced stomach in connection with 

July 8, 1893. 

Clinical Lectures. 


movable kidneys, claiming that in 89 cases 
in which he distended the stomach, he 
found an enlargement, perspectively a 
prolapsus, 79 times. This number seems 
to the author to be questionable, since, 
among his 100 cases, in which he fre- 
quently made use of distending the sto- 
mach, he found but 17 in which he could 
demonstrate enlargement or prolapsus. A 
question now comes — if and how much 
pathological importance can be attached 
to the palpation of kidneys ? 

In order to arrive at some definite con- 
clusions, the author studied, in each case 
very thoroughly, the subjective as well 
as objective symptoms. After the diagno- 
sis had been made, seven patients were 
found who had suffered absolutely from 
the mobility of the kidneys ; 8 in which 

other diseases were present, anemia, tu- 
berculosis, etc., who complained, however, 
subjectively, only of the movable kid- 
ney. This ^brings the percentage down 
to 15. 

It has been known for some time that 
floating kidney, or even the second grade, 
ren mobilis, may give rise to serious 
changes, either by dragging on the liga- 
ments or by flexure of the vessels or ure- 
ters. The author does not conclude that 
these conditions arise from pathological 
changes, but that the cause may be sought 
within the physiological boundaries which 
often cause abnormalities. 

Therapeutically the author recommends 
certain bandages, or a corset extending to 
the puoes, which will in a measure produce 
artificial abdominal walls. 





Gentlemek: — When a sore throat is 
due to a phlegmonous inflammation it at- 
tacks the tissues somewhere about the ton- 
sil, but not the tonsil itself. Here at 
once we strike at the root of the popular 
idea that in quinsy sore throat the abscess 
occurs in the tonsil. It does not. In 
quinsy sore throat, the favorite seat of the 
phlegmon is in the tissues just in front, 
just above and to the outer side of the ton- 
sil; or, in other words, just behind the 
anterior pillar of the fauces. The phleg- 
mon, starting in this locality, invades the 
tissues about the tonsil — the anterior pil- 
lar of the fauces and the connective tissue 
behind and above the tonsil. Its next 
most frequent locality, but much more 
rare than the other, is behind the tonsil 
in the posterior pillar of the fauces. In 
the connective tissue of this part the phleg- 
mon makes much slower progress and is 
never as large as in the first form. There 
will be oedematous infiltration and swell- 
ing, and the phlegmon will extend down 

"^Professor of Diseases of the Throat and Nose, 
College of Physicicians and Surgeons, New York. 

the lateral pharyngeal wall, and it may 
eventually point as low down as the mouth 
of the oesophagus, the last place you 
would look for it to point. The third form 
is the still more rare. Here the phleg- 
mon locates itself in the groove behind the 
tonsil, between the two pillars of the 
fauces. Here also the phlegmon has 
nothing whatever to do with the tonsil, 
but the abscess penetrates into the tonsil 
and opens into one of its crypts. Such 
an abscess will discharge itself unexpect- 
edly, and you may never know where it 
was located or how it discharged itself. 
This phlegmonous inflammation will prob- 
ably locate itself in eighty per cent, of the 
cases in the first locality mentioned. 

These are the three localities in which 
you will find a peri-tonsillitis. In the case 
before us, the phlegmon certainly looks as 
if it were in the tonsil, for the tonsil is 
displaced and swollen, but in reality it is a 
case of peri-tonsillitis. 

Now, ordinarily, the exciting cause is a 
cold, and the predisposing causes are just 
such large, ragged, irregular tonsils as you 


Clinical Lectures, 

Vol. Ixix 

see in the drawings before yon. The open 
mouths of their crypts seem to invite in- 
fection. In perhaps eight cases out of 
ten, the rheumatic diathetis will be the 
predisposing cause. I know very well 
that there are cases of idiopathic peri-ton- 
sillitis, where the tonsil is scarcely swollen 
appreciably, and where there is no history 
of rheumatism or of exposure, and yet 
quinsy sore throat develops; but these 
cases are decidedly rare. Where peri- ton- 
sillitis occurs and recurs. Spring and Fall, 
year after year, in the middle-age — not in 
children or old people — you will find that 
the subjects are almost always rhenmatic. 

In our patient here, the tonsils have a 
deep bluish-red color, which involves not 
only the tonsils but the parts about the 
tonsils ; the soft palate is congested as far 
up as the hard palate ; the anterior pillar 
of the fauces is crowded forward, oedema- 
tous and of the same bluish-red color. 
The other side shows only the bright red 
color of acute congestion. The tonsil is 
pressed forward to the median line and 
you see the open mouths of a number of 
the crypts. In this acute, hyperaemic 
swelling, and this bluish-red color, and the 
displacement of the tonsil you have the 
characteristics of quinsy sore throat or 

The symptoms to which this condition 
gives rise are most marked and painful, 
and I know of no affection of the throat 
in proportion to the grade of the inflam- 
matory action, which can give so much 
pain and discomfort as a quinsy sore throat. 
In protracted cases, where the pus forms 
low down in the pharynx, or in the pos- 
terior pillar of the fauces, the tissues here 
being denser, the physician is compelled 
to watch the gradual approach of these 
abscesses to the surface without being 
able to give much relief to the patient's 
suffering. These cases recur regularly 
every Fall and Spring until the patient 
reaches that period of life when the affec- 
tion disappears of itself. The pain is 
deep-seated and lancinating at first, but 
soon becomes throbbing and agonizing, and 
to the patient who has had a quinsy sore 
throat is a positive indication that another 
attack has begun. Soon deglutition be- 
comes absolutely impossible, and respira- 
tion is impeded because the fauces are 
blocked up b}^ the hypertrophied and 
swollen tonsil. The pain is constant and 
radiates toward the ear of the affected 

side; the tongue is swollen and coated; 
the saliva constantly dribbles from the 
corner of the mouth, partly because he 
cannot swallow the saliva and partly be- 
cause there is an increased secretion of the 
saliva. The patient cannot lie down and 
sleep for fear of suffocation, and he can- 
not eat on account of the pain and ob- 
struction; he can scarcely speak; he is 
worn out, wearied, nervous and apprehen- 
sive. To the experienced eye, this picture 
is in itself sufficient for a diagnosis. I 
know of no affection of the throat which 
can simulate quinsy or peri-tonsillar ab- 

I pass on now to the second form of 
acute tonsillar disease — acute follicular 
tonsillitis. This is a very common form 
of acute disease of the tonsil; it is an 
easy one to study and understand, and an 
easy one to treat, but there are certain 
practical points to which I must ask your 

First, then, what is an acute follicular 
tonsillitis ? To the best of my belief to- 
day, we are dealing in acute follicular ton- 
sillitis with a germ disease, with a blood 
poison which has its local manifestation in 
the tonsil. I believe that if certain pre- 
disposing conditions exist — for instance, 
large, ragged, hypertrophied tonsils — a 
simple, catarrhal imflammation of the 
throat may be suificient to make the soil 
favorable for the reception of that little 
germ which comes through the air, and 
entering the open mouths of the follicles, 
finds a lodgment there, and creates there 
a croupous inflammation which is the 
characteristic of follicular tonsillitis, and 
also gives rise to a blood poison which pro- 
duces a marked constitutional disturbance 
of which I shall presently speak. Or it 
may be that the germ enters the blood and 
sets up there those poisonous changes 
which produce again the constitutional 
symptoms, and flnally, produce the local 
manifestations in the throat. At any 
rate, please bear in mind that I consider 
it to be a germ disease. Although this 
germ has been eagerly sought for by com- 
petent microscopists, it has not been dis- 
covered, and we simply infer its existence 
from the clinical phenomena which this 
disease presents. 

As I have said, a croupous inflammation 
is established in the lining mucous mem- 
brane of one or more follicles, and blocks 
up the follicles, and this obstruction is as- 

July 8, 1893. 

Clinical Lectures. 


sisted by blood corpuscles^, bacteria, for- 
eign bodies and the like. The follicle 
having become filled, its contents overflow, 
as it were, around the mouth of the fol- 
licle in the form of a whitish, ovoid, clean 
looking little mass. A. number of these 
masses may become confluent, giving rise 
to a larger pseudo-membrane; or they may 
remain separate, and the tonsil will then 
appear to be dotted over with these whitish 
follicles. Both tonsils are usually affected 
in follicular tonsilitis. 

The constitutional symptoms are 
marked. There is a decided elevation of 
temperature; in the adult, the tempera- 
ture not uncommonly reaches 101° or 102° 
and in children it is not unusual to find a 
temperature of 104° or 105°. This fever 
is associated with a rapid, tense pulse, ex- 
treme lassitude and a general aching of 
the whole body. During the first twenty- 
four or thirty-six hours there is profound 
prostration, with marked febrile move- 
ment. After awhile deglutition becomes 
difficult and, if you examine the throat at 
this stage, you will see the little white 
points appearing on the surface of the ton- 
sils. As they grow, the urgency of the 
symptoms disappears. The disease runs 
its course in from five to seven days, but 
the marked constitutional disturbance 
only lasts for about forty-eight hours. 

How shall you make the differential 
diagnosis between a follicular tonsillitis 
and diphtheria ? You are constantly 
called upon to do this, off-hand, at once, 
and absolutely. Let me say frankly, that 
there are many cases in which the differ- 
ential diagnosis between an acute follicu- 
lar tonsillitis, where a large pseudo- mem- 
brane has formed on the tonsil, and diph- 
theria, in the early stages, is extremely 
difficult, and I would blame no man, how- 
ever great his experience in throat dis- 
eases, if he insisted upon time for his 
diagnosis. In the meantime, however, 
every precaution must be taken to prevent 
a possible spread of the disease. 

Let me mention a few of the practical 
points which I carry in my ovvn mind 
when brought face to face with such 
cases. In the vast majority of cases 
they will enable you to make a correct dif- 
ferential diagnosis. 

1. Remember that the membrane of 
diphtheria does not remain confined to the 
tonsil, but that it spreads to the uvula, 
soft palate, and perhaps to the post-phar- 

yngeal wall ; in other words, it may leave 
the tonsil. The pseudo-membrane of fol- 
licular tonsillitis never does this. 

2. The membrane of diphtheria is so 
closely adherent to the underlying parts, 
and you cannot lift it up from the mucous 
membrane without rupturing the capillary 
vessels, causing a slight bleeding. The 
pseudo-membrane of follicular tonsillitis 
is easily raised from the underlying mu- 
cous membrane with a probe ; it leaves no 
abraded surface beneath it, and very often 
you can draw out with the pseudo-mem- 
brane the contents of the follicle, the 
mouth of which it covers. 

3. The diphtheritic membrane is always 
thick. In follicular tonsillitis the mem- 
brane is thin and delicate. 

4. The membrane of diphtheria is al- 
ways of a dirty, yellowish color; the 
pseudo-membrane of follicular tonsillitis 
is pure white, or of a pearl-gray; it is 
clean and bright. The membrane of 
diphtheria after twenty -four or forty-eight 
hours becomes necrotic, and takes on a 
dirty, blackish-gray color — in short, it 
looks what it is, a necrotic, dead, or dying 
membrane. The pseudo-membrane of 
follicular tonsillitis on the other hand, 
always remains whitish, pearl-white or 
gray, and never becomes blackish or ne- 

5. The tonsillar portion underlying the 
diphtheritic membrane is of a deep red or 
bluish-red color; the underlying tissues in 
a case of follicular tonsillitis is bright red, 
never of a very dark, angry color. 

These points, I am sure, will assist you, 
as they have often assisted me in making 
the differential diagnosis between diph- 
theria and the pseudo-membrane of acute 
follicular tonsillitis. Of course, we can 
go further, and with the microscope de- 
termine the presence or absence of the 
Loeffler bacillus, but I have given you the 
practical, bedside tests which will usually 
enable you to answer definitely and quickly 
regarding the true nature of the mem- 

Now, let me say a word about the con- 
tagiousness of follicular tonsillitis. Here, 
I must deal largely with the individual be- 
lief. I believe to-day, as a result of my 
own experience, that follicular tonsillitis 
is mildly contagious; that it is not safe to 
put others in the way of direct contagion ; 
and my advice to you is that it is best to 
isolate the patient, and particularly to 


Clinical Lectures. 

Vol. Ixix 

keep children from being around those 
suffering from this disease. You should 
also banish from the sick room adults 
having hypertrophied tonsils, or suffering 
from any condition which predisposes to 
such a contagion. 

To simplify the treatment for you, I 
have had the principal points printed on 
these sheets of paper, and will distribute 
them among you. I shall run over them 

First, then in the treatment of peri- 
tonsillar abscess, in the interval of the at- 
tacks, extirpate the tonsils, and get rid of 
this predisposing cause. In the treat- 
ment of the acute attack, I would say 
that an attempt to abort an attack is oc- 
casionally successful, but it will never do 
it after the first twenty-four hours; there- 
fore, if this period be gone by, immediate- 
ly administer anti-rheumatic remedies, 
such as sodium salicylate, salol, oil of 
wintergreen, and iodide of potassium, and 
with the first four doses, give one drop of 
Fleming's tincture of aconite. As a rule 
no more than four doses of this powerful 
drug should be administered. If sodium 
salicylate be prescribed, give about ten 
grains, every hour. Another useful meas- 
ure is to allow the patient to frequently 
apply bicarbonate of soda to the tonsil 
with the moistened finger, for it gives 
great relief to the patient, although I can- 
not say why it does it. I constantly see 
tonsils which have been cut and maltreated 
in various ways ; I have told you that the 
abscess is not in the tonsil, and therefore, 
it is folly to incise the tonsil. Blood-let- 
ting by puncturing the tonsil will relieve 
the tension and pain, but I tell you, never 
scarify. As soon as the existence of pus 
is established by digital palpitation, open 
the abscess by a free incision. The gen- 
eral local treatment consists in gargling 
the throat with water as hot as can be 
borne, the use of alkaline and disinfectant 
sprays to wash away the accumulated tena- 
cious mucus; inhalations of steam, or the 
application of hot flaxseed poultices, fre- 
quently renewed, beneath the angle of the 
jaw. An application of a five or ten per 
cent, solution of cocaine will allay the 
pain. The abscess usually forms by the 
third day, unless it is in dense tissues. 

Now, the treatment of acute follicular 
tonsillitis is simplicity itself, notwith- 
standing the great variety of drugs and 
methods recommended in our various 

medical works. Every case of follicular 
tonsillitis can be successfully and quickly 
treated by the following method : 

For the stage of fever and lassitude, 
there is perhaps nothing better than anti- 
pyrine. Later on, nothing is better than 
quinine and strychnine for the physical 
prostration. Locally, you should admin- 
ister every hour a half teaspoonful of the 
following, which should be slowly swal- 
lowed, in order that it may diffuse itself 
about the fauces : 

T> Tinct. Ferri Chloridi dr. ij . 

J^ Glycerini oz. ij. 

You may also apply the tincture of the 
chloride of iron at regular intervals during 
the day directly to the croupous deposits 
on the tonsils, using a kalsominer's brush, 
one inch wide, which is very much better 
than the ordinary throat brush. An an- 
tiseptic and cleansing gargle is also grate- 
ful to the patient. A mixture of listerine 
and water may be used for this purpose. 

In conclusion, then, remember to use 
the knife whenever necessary, avoid poly- 
pharmacy, assist Nature to do her work^ 
and follow the few simple rules which I 
have given you. 

Operating Accident. 

A sad and unusual accident is reported 
to have occurred recently in the operating 
theatre of one of the London hospitals. 
One of the surgeons was engaged in sew- 
ing up the wound after a laparotomy, and, 
while in the course of doing so, he seems 
to have given a flourish to the needle in 
his hand, which penetrated one of the eyes 
of his assistant. The latter continued for 
some moments to attend to his duties, but 
was afterward compelled, owing to the 
pain in his eye, to leave the side of the 
operating table and sit down on one of the 
benches in the theatre. As soon as the 
operation had been completed, the surgeon 
examined the injured eye of his assistant, 
and found the lens was lying outside the 
organ, the sclerotic extensively torn, and 
the vitreous protruding. — N. Y. Med. 

A lady in distress wrote the following 
urgent note to her physician: '^ Dear Dr., 
please call at once, and bring your urethra 
with you." He took a catheter. 

July 8, 1893. 





My Professional Brethren — I have not 
ventured to bring before you any new 
theme, or one which would in any way 
depend upon the eloquence or the special 
capability of the speaker. I have felt 
that on an occasion such as this, when you 
have honored me by asking for an address 
at the general meeting of this great asso- 
ciation,! might most usefully occupy your 
attention by dealing with the subject 
which, from its own intrinsic importance 
and from the influence which it is likely 
to have, which it can hardly fail to have 
ultimately on the welfare of the popula- 
tion and the nation, should at least intrin- 
sically demand your attention, whether 
you give entire assent or not to the propo- 
sition I shall have the honor to lay before 

In dealing with the subject of cholera 
I am dealing with one which has been 
perhaps more written about, more dis- 
cussed, and more talked about than any 
other in our time. It is the subject of 
almost universal conversation. Since I 
have been here, questions have been put to 
me not only daily, but almost hourly. 
One is, " What do you think of our coun- 
try ?" as to which you may readily ima- 
gine I have been giving answers which I 
am certain have been very satisfactory. 
Second, ' ' What do you think of the 
cholera?'^ "Is the cholera coming?" 
Then I will venture to mention briefly 
what I wish to be able to present to you 
to-day by an incontrovertible amount of 
evidence. That is, cholera is no longer a 
thing to be dreaded ; it is no longer a 
thing to be wondered at ; it is no longer 
beyond control. Although it is only a few 
years since we in Europe and you in Amer- 
ica made the acquaintance of cholera, and 
when we first came in contact with it, it 
was the most striking and awful pestilence 
known to our profession. However, the 
study and application of a single practi- 
tioner — an obscure practitioner, but one 
of the greatest of the world^s heroes — the 

* Address to the Members of the American Medical 
Association, Thursday, June 8, 1893. 

studies of one man carefully followed out 
have robbed cholera of all its mystery; 
have pointed out its causes, and have put 
before us methods of extinction so certain 
and so easy that it will be a reproach to 
every nation, and especially a reproach to 
those great nations so endowed by nature, 
if in our own time cholera does not be- 
come as thoroughly extinct — as nearly ex- 
tin-ct, as much a matter of the past — as 
typhus or the oriental plague, which have 
been conquered by medical skill and med- 
ical advice. 

Every theory, every advance in knowl- 
edge, goes through certain very well 
known stages; as a rule, at the beginning 
it is denied. That is wholesome and nec- 
essary for the proof of its accuracy. The 
skeptic attitude is the necessary attitude. 
Presently it is ridiculed, and then comes 
the stage where its leading facts are ac- 
cepted. Presently they are accepted, and 
finally they become so contrite everybody 
says "0 yes, we have always known 

A distinguished gentleman I have seen 
here to-day reminded me, in our early 
text books, the knowledge of cholera was 
summarized in about these words, 
"Cholera — Diagnosis, easy; etiology, 
uncertain; causation, unknown; treat- 
ment, useless." Well, now we have mod- 
ified all that. If I had to take those 
headings to-day, I think you would agree 
with me in saying this: Diagnosis, diffi- 
cult, very difficult — I will show you pres- 
ently how difficult it is; thus, it is not at 
all desirable, for the commercial interests 
of the community, that cholera should be 
too quickly identified, and where it ap- 
pears in its first early stages it is spoken 
of in the most endearing terms. When 
cholera first comes it is reported as choler- 
ine — an attractive word. Presently, like 
the pleasant little French songs, it be- 
comes, cholerine-cholera, cholera-choler- 
ine. But, there is nothing more difficult, 
as our recent science has shown, than the 
diagnosis of cholerine from cholera, and 
there is nothing a microscopical examina- 



Vol. Ixix 

tion will show, whether the early or late 
cases are cholera or cholerine. The diag- 
nosis is no longer easy. We have yet a 
great deal to learn about the stages which 
characterize simple cholerine and Asiatic 
cholera. Another thing, cholera does 
not stop, as we suppose. You notice the 
importance of this in connection with the 
enormous expenditures and the disgrace- 
ful efforts to keep it out — a disease which 
we have invited, and, having invited by 
our negligence, try to keep out with 
quarantine. They are obliged, in virtue 
of their dirt, to fight a disease invited by 
dirt. It was at one time supposed a man 
with cholera must go through certain 
stages and quarantine was sufficient, but 
you now know the man may walk about 
with the cholera and may contaminate an 
entire water-supply. He may, as at one 
time, cause 16,000 cases of cholera with 
6,000 deaths. Cholera, then, is not easily 
diagnosed. It is only capable of diag- 
nosis by bacillar examination. 

Further than that, you know now very 
well a man may walk out of a cholera hos- 
pital cured, so-called, but with a slight 
diarrhoea. He may infect a river and 
may slay a community, for his discharges 
are often laden with germs. In three 
cases examined for me, the dejections 
were found to be loaded with bacilli. You 
see, then, diagnosis is not certain. We 
can always know when cholera is about, 
and should take extra care of all these 
cases of cholerine and premonitory diar- 
hoea. Now, as to the pathology. The 
pathology I will not stop with to-day. 
The pathology has now been immensely 
cleared up, and the pathology of cholera 
is now no longer mysterious. We know 
how to deal with it as we do our other 
bacteriological diseases. Treatment, use- 
less; we know no more of the treatment of 
cholera now than we knew of the treat- 
ment of cholera thirty years ago. And, 
that is no reproach to us, because for 
poisons you may find antidotes or partial 
antidotes, but an infective disease must 
run its course. 

We know now there is such a thing as 
an evolution of disease. Cholera is one 
of those diseases which the public like to 
think of as a disease which comes by prov- 
idence and goes by drugs. That is exact- 
ly the opposite of the facts. Cholera 
comes by man; it is a man-created disease, 
and cholera cannot be cured by drugs. Of 

course, there are drugs which alleviate and 
diminish the symptoms. Possibly there 
are drugs which diminish the number of 
deaths. But, as at the last Hamburg epi- 
demic, in the early stage and in the later 
stages of epidemics, when patients are 
going to get well, everything will cure, 
and that is the time to try specifics. But, 
in the essential periods, when the epidemic 
is at the height, no drugs will modify the 

Now then, as to the causation. We are 
entitled to say in some parts of Europe 
cholera will never appear again, and with 
certain precautions here cholera never can 
appear again. Now, let me take you 
briefly — I have here an immense mass of 
figures, but let me take you briefiy over 
the history and analysis of the great epi- 
demics of cholera since 1853, in order to 
prove from that precisely the point I am 
endeavoring to bring to your notice. You 
know, our first outbreak of cholera in 
Europe was in 1832. I was just looking 
here — I expect some here will remember 
1832. Well, the Annual Eegister said 
the cholera left medical men with most 
opposite views. We know, first of all, 
it is epidemic and not endemic. We know . 
it always comes from one place. I am 
ashamed — I am grieved, more than ashamed 
— to have to name that source of danger 
of pestilence to Europe and the world. 
That is India. It is within the Imperial 
British domains of India cholera is always 
found. In the earlier outbreaks from 
India, cholera usually came across the 
great seas, across the Caucas, and then by 
caravans and emigrants reached other 
towns, and finally that ill-fated city, Ham- 
burg. And then, through Hamburg to 
Europe in general. The other route was 
by the Mecca pilgrims, the India pilgrims 
who carried cholera with them to Mecca, 
and there, by a process I will show you, dif- 
fused it throughout the whole of that 
country, and then brought it on to Alex- 
andria. Erom Alexandria it took ship 
and came to Havre or came to England. 
That is the course it has pursued now on 
25 different occasions. And, I notice 
this: When people travel on foot, on 
horseback, by caravans, cholera travels 
correspondingly slow with them. It took 
three years to come from Odessa to Europe. 
And, as steamships and railways have in- 
creased, its speed has increased. Cholera, 
then, travels along the lines of human in- 

July 8, 1893. 



tercoiirse and precisely with the rapidity 
of human intercourse. It makes no back- 
ward course. It has its back currents as 
people rest in a place; it has recurrence 
as the infection lies dormant. The next 
point is, that cholera, when we come to 
examine the facts, is a disease which is 
always carried by dirty people to dirty 
places and diffused by dirty water. 

Now, let us take the places to which it 
was carried and see what is the demonstra- 
tion I can offer you that it was carried by 
dirty water. Well, we will take, first of all, 
as an example, London. When cholera first 
came to London everything was mystery. 
It was in 1851. We did not know how it 
came. We thought it was blown by the 
winds, carried by pandemic waves, and we 
heard of cholera mists, telluric and mete- 
oric influences and all that jargon. Then 
came one or two more instances. There 
was a celebrated pump on Broad Street; it 
was celebrated and the water most beauti- 
ful and sparkling. But water sparkles 
from human nitrates! Well^ the Broad 
Street pump was a celebrated pump and 
people were sending from all over London 
to drink the water. It was suggested that 
it was precisely the people who were sup- 
plied with that water who were the ones that 
died. A clergyman came up and drank the 
water. It was very noticeable that he 
drank brandy with the water, for it was 
thought brandy corrected the influence of 
the water. We, of course, know it does 
not. The whiskey hurts you and does not 
correct the water. 

This gentleman drank brandy in his 
water and ate a mutton chop, and spoke 
of his brethren who had died, and then he 
went home and died. It was afterward 
found this water became sparkling because 
of matter from the sewers from the 
neighboring hospital. This demonstration 
was carried on, and it was found the 
amount of cholera in all these subsequent 
epidemics in London were in precise rela- 
tion to the water supplied with the animal 
matter. Of course, animal matter is not 
pleasant to drink, but some old ladies will 
not change their drinking water, saying 
that their fathers and grandfathers have 
drank it and they refuse to change. Of 
course, it will not kill until poison gets 
into it. 

In London there are the water compan- 
ies. During the first epidemic the Lam- 
breth company was the purer. About 137 

per 10,000 of the population supplied with 
that water died with cholera, and only 
about 67 per 10,000 of those supplied by 
the other company. The experiment was 
so large and complete there could be no 
mistake about it. Houses side by side 
were supplied by companies furnishing 
water of various degrees of purity By the 
time the second epidemic appeared, the 
second company went a great deal higher 
up for the water supply, and the water 
was much purer. The proportion of 
deaths then was just inverted. It now 
had 30 per cent, less deaths than the com- 
pany formerly more innoculous. A very 
ghastly experiment. There is nothing so 
sensational in the world. If you, who dis- 
cuss sanitation, would take trouble to put 
it in a dramatic form, there is nothing 
which could so seize the public mind. Now, 
comes the next fact. In 1866 — I w^as then 
23 years of age — cholera broke out in 
East London. I had no skilled, expert 
hand, but was firmly convinced fiom 
study that its cause must be the water and 
nothing but water. I got, then, a very 
well-known gentleman to go down and 
look at the companies' works, and he came 
back and said, "There is nothing there. 
The engineer says the water is the ordin- 
ary water supplied in the ordinary way 
and there has been no change.^' The 
same result followed an investigation on 
the second day, but on the third day I 
found "Pump out of repair" on the books. 
Well, to make a long story short, I found 
one huge pump had been out of order and 
all the water was pumped directly into the 
district, that was affected with cholera, 
without passing through the filter bed. 
They were supplied with this water two 
days before the cholera broke out. Well, 
that was a very striking fact. Then we 
found it was only people of that district 
who were suffering with cholera. Lon- 
don escaped, for the district supplied by 
each company is limited by Act of Parlia- 
ment, .but in five weeks 16,000 people 
were taken with cholera and 6,000 died. 

We will now trace how the cholera got 
into the water. A ship had come by the 
well-known route from Alexandria with 
only six or eight cases of cholera on board. 
The vessel was put in quarantine, the pa- 
tients put in the hospital, and we had 
almost forgotten it ; but when this occurred 
we traced these cases and found one had 
gone to a small town. And there only 



Vol. Ixix 

16jj@^' people were killed, including the 
man," the doctor, the nurse, and 13 people 
of the village. But then came this other 
fellow, who was discharged as convalescent 
and had gone to a cottage on the river, 
the sewers of which connected with 
the river. He was taken with relapsing 
cholera. (If you poison rabbits with 
cholera bacilli, they will get w^ell; but 
shortly they have relapsing cholera, when 
the intestines will be found full of cholera 
bacilli.) Well the man infected the river 
just at the very moment the water was 
taken from this point, in consequence of 
the breaking down of the pump, and dis- 
tributed over the town. Thus one un- 
happy man and one unhappy engineer 
combined to kill all these people, and all 
got off Scott free. If any man sells me 
poison, as many a man does by accident, 
as an unhappy chemist sells morphia for 
ice cream, or a baker sells flour mixed ac- 
cidentally with arsenic, even for his acci- 
dent you have legal recourse against him; 
but against the distributing of poison by 
your water companies you have no recourse. 
Your municipalities are entitled to distri- 
bute cholera at intervals, typhoid fever 
daily and constantly, in all your great 
cities, and to poison their unhappy clients 
and yet go Scot free. They suffer no 
damage, and you have no remedy against 

Well now I can show you that is true 
always with cholera. Since 1866, every- 
body has been so far convinced of the ac- 
curacy of this statement that our main 
experiments have been on water supply. 
In England we have spent thirty-five 
hundred million dollars on water supply, 
one hundred million dollars within the 
last year on water supply. I am satisfied 
we can never have an attack of epidemic 
cholera in England again. Our water 
supply is not perfect, and we may have 
limited outbreaks of cholera, but our 
water supply now places us in much bet- 
ter shape. We have no fear, and can have 
no fear of cholera in Great Britain. 

The great seats of cholera epidemics 
have been Spain and Italy. And every- 
body knows, of course, of Hamburg. In 
Hamburg they knew they were drinking 
the filthy and impure Elbe water. But 
Hamburg is a free municipality — suffi- 
ciently under control of the citizens to 
leave them free to do a good deal of evil 
and not to do a great deal of good. The 

greatest mortality rate in Hamburg was 
down near the river, while further away 
from the river the mortality rate was much 
less. Hamburg is as absolute a demon- 
stration of the water-born theory of chol- 
era as the world has ever seen. Also the 
recent outbreak in the dead of winter near 
Berlin, where cholera broke out in a lu- 
natic asylum, was a mystery. But it was 
found a single person had come on from 
Berlin. In Hamburg, by. the way, they 
have a most beautiful system of ir- 
rigation. Charming! And the engineers 
have so arranged matters that the sewer- 
age all passes out the same way into the 
river. Just below the outlet of the sew- 
erage is the intake of the water supply. 
And to make things worse, this being in 
the dead of winter, everything was frozen, 
and the matter was taken up by the water 
supply very nearly pure. So, three or 
four days after the gentleman came to the 
hospital from Berlin, they had a tremen- 
dous outbreak of cholera. That is also 
the history of all Paris outbreaks. In 
Paris, during the warm season, a notice 
is put up stating the water now is mixed 
and yoa are only to drink such and such 
water. But a great many people cannot 
afford to drink from that supply, and 
they always have outbreaks of typhoid 
and cholera in Paris caused by the impure 
water supply, and it is stopped as soon 
as the water supply is changed. 

And I may say, if it is supplied with 
pure water, they will never have another 
attack of cholera in Paris. Marseilles 
and Tulon are in the same condition. In 
Marseilles impure water is taken in, and 
they pass it out again, running great 
quantities over the streets to clean them. 
But, cleaning the streets will not stop 
cholera if you are drinking impure water. 
After heavy rains, cholera is usually di- 
minished ; but, after heavy rains in Mar- 
seilles, it was increased because the un- 
happy people were drinking the water 
from the rivulets. That was the cause of 
the cholera in 1866. When that epidemic 
reached us, I received a telegram, stating 
my water-born theory of cholera was at 
fault. Well, the water theory cannot be 
at fault. '^ Trace your water-supply up 
to the top,^' I told him, and he soon an- 
swered, "Cause found." They had 
traced it up to the top, and found the 
cause up the mountain. Cholera was 
prevalent along the frontier, and they 

July 8, 1893. 



had the whole frontier lined with police 
and soldiery. These camped at the top 
of the water supply. That supply was 
cut off, and the city deprived of water 
from that source, and cholera ceased with- 
in a week. That was a very striking 
case. Another striking case, perhaps 
more striking, was in Is"aples. I saw a 
little paragraph, stating, we are all very 
much afraid of cholera and we are taking 
every precaution at hand. A few cases 
have broken out. We are pouring large 
quantities of carbolic acid in the cess- 
pools, and, odd to say, and disagreeable 
enough, our drinking water all tastes of 
carbolic acid. ■ What happened was, 
cholera came, and there were 70,000 
deaths — the most calamatous and vast 
catastrophy of modern times. The doc- 
tors were attacked and assassinated. 
They have since taken better precautions 
than religious processions or attacking 
the doctors. They have obtained pure 
water from beautiful aqueducts. ISTaples 
is immune from cholera. By a coinci- 
dence, little outbreaks occurred, and at 
the precise period when the aqueduct was 
being repaired, and at the moment it was 
repaired the cholera ceased. Naples, 
from being the most susceptible to cholera, 
is now one of the most immune, as any 
great city may become when you compel 
your municipalities to do their duty, to 
supply pure water, pure air and pure 

I shall not now detain you further than 
to point out this, that the latest results of 
microscopical examination and bacteriolo- 
gical research fully confirm this vast mass 
of evidence, collected from every city, 
every country, every epidemic of the last 
half century. Whereas, clinically and 
statistically, we can say on a basis of facts 
and figures, there never has been a coun- 
try experience an outbreak of cholera, 
where the cause cannot be traced to the 
distribution of infected water. That is a 
matter of clinical observation. So, we 
may say scientifically now, we thor- 
oughly understand why that is. We 
know the characteristic cause of cholera 
is a bacterium, which has this simple 
property: It is not in itself, and while 
fresh, very poisonous ; that it is not an 
an^robe but is an aerobe, and its favorite 
method of development and propogation 
is in soil and water. The cholera bacillus 
is not easily communicated in the fresh 

stage, and it is not easy to infect guinea 
pigs or other animals with it, but if you 
cultivate it or let it cultivate itself in 
water, it becomes very effective, and be- 
comes more virulent as it is multiplied in 
soil and in water. It is interesting, by 
the way, to notice it is difficult to infect 
healthy guinea pigs ; but if you dose them 
with brandy or whisky and make them 
unhealthy, or if you give them opium, 
they are easily infected. Acid drinks, 
sulphuric acid and citric acid, have been 
shown to be very useful as preventatives. 
So, all these experiments confirm the 
broad facts which we have been able to 
learn from the examinations, and the final 
result is, if we can exert our influence 
upon State boards of health, to bring 
home a sense of responsibility to the exec- 
utive officers of State, we shall be able to 
boast as a profession that we have in our 
generation pointed to the extinction of 
two great plagues of mankind. We have 
shown how three plagues can be extermi- 
nated, and we should hear no more from 
typhoid fever or typhus fever. Deaths 
from these diseases are just as much vio- 
lent deaths as deaths from arsenical pois- 
oning. They should be the subject for 
inquest, and it is for us to extend, not 
only to the rich who can buy mineral 
waters of all sorts, but to the poor who can- 
not always obtain sterilized water or boiled 
water, and for whom we ought not indeed 
to poison the water and require them to 
purify it. We should always be supplied 
with pure drinking water. 

The devil shoots hard at the man who 
makes an honest tax return. 

Put a Strong Stick in it. 

The drug-store proprietor had employed 
a new boy for 83 a week. " I'll have a little 
stick in mine," said the man at the soda 
water counter. '' A little what?" asked the 
boy. '' A little stick," repeated the man 
with embarrassment. "In your soda- 
water?" "Yes, of course." " The boy 
prepared the mixture. The man took a 
swallow, gasped, gurgled, and coughed, 
and, when he caught his breath, said," 
" What in thunder did you put in that 
soda-water?" " Well, sir," replied the boy, 
"Iwouldn^t have done it if you hadn't 
insisted ; but as long as you wanted it I gave 
yoLi the best brand of mucilage there is in 
the shop." — Wa§Mngf07i Star. 



Vol. Ixix 



MARY SHERWOOD, M. D., Baltimore, Md. 

In a report of 5 cases of laparotomy 
performed on patients over seventy years 
old, published in the Lancet^ January 21, 
1893, J. Rutherford Morison states: 
^' Long lists of successful ovariotomies can 
no longer serve any good purpose, for it 
has been proved that the mortality of 
ovariotomy should not exceed 5 per cent. 
My excuse for publishing the following 
cases is the advanced age of the patients. 
Sir G. M. Humphrey long since pointed 
out that in old people repair and recovery 
are likely enough to follow major opera- 
tions. This is true of abdominal sections 
— a fact not sufficiently recognized." 
That this statement is emphasized by facts 
is shown most conclusively by the statis- 
tics in the list of 100 cases of ovariotomy 
performed on patients over seventy years 
of age, which I have recently assisted Dr. 
Howard A. Kelly in collecting. While a 
complete tabulated statement of these 
cases, with an analysis of the same and 
inferences drawn therefrom, is reserved 
for publication in th.Q Johns Hoshins Hos- 
pital Reports, at the suggestion of Dr. 
Kelly I have taken the cases reported by 
American operators as the basis of the 
present paper. 

That special attention might be called 
to the cases of American surgeons seems 
appropriate as this list includes : 1. The 
earliest case found in the literature on the 
subject; 2. The oldest case on which 
ovariotomy has been successfully perform- 
ed; 3. The greatest number of cases re- 
ported by any single operator. 

The first ovariotomy on record as hav- 
ing been performed on a woman over sev- 
enty years old, was the case of E. P. and 
Wm. 0. Bennett, of Danbury, Conn., who 
on the 17th of August, 1861, operated on 
a patient aged seventy-five years. An 
incision two inches long was made and 
seven or eight sacs emptied with a tro- 
car. Silver sutures were used in closing 
the abdomen. The patient "recovered 
without any mishap." 

To Dr. John Homans, of Boston, be- 
longs the honor of having operated on the 
oldest case on record. In the Boston 
Medical and Surgical Journal^ May, 1888, 

he reports a case of ovariotomy in a 
patient aged eighty-two years and four 
months. He removed a multilocular 
cyst of the left ovary, weighing fifteen 
pounds, and in December, 1892 — four 
years after operation — reports the patient 
as alive and well. In addition to having- 
operated on the oldest case recorded. Dr. 
Homans reports 12 cases of ovariotomy in 
women over seventy years of age, the 
greatest number accredited to any single 

The table included in this paper con- 
tains 38 cases from the original list. Of 
this number, 33 recovered from the opera- 
tion, 5 died, giving a mortality of 13.1 
per cent. The mortality as based on the 
complete list of 100 cases is less than this 
(12 per cent.). The results of the opera- 
tion are, therefore, very encouraging 
when one considers that, according to 
Bland Sutton, in experienced hands the 
mortality of ordinary ovariotomy varies 
from 5 to 10 per cent. This rate of mor- 
tality becomes increasingly suggestive 
when it is noted that in the series only 9' 
cases are reported as simple and uncom- 
plicated. In 23 cases adhesions were 
more or less numerous, necessitating in 2 
cases the removal of the uterus. In this 
connection the table seems to establish the 
fact that age in itself need not be consid- 
ered an additional factor in the prognosis 
of ovariotomy. In the case of Boldt, the 
patient was seventy-four years old, cachec- 
tic, and much emaciated, with moderate 
ascites. The entire tumor was firmly 
adherent, many adhesions so dense as to 
require severing with scissors or knife; 
there were also adhesions with intestines. 
The retro-peritoneal glands were enu- 
cleated. The tumor proved to be a multi- 
locular cyst of the left ovary of which the 
lower and posterior portions as well as the 
enucleated glands were carcinomatous. 
This ojperation was performed in March, 
1887, and Dr. Boldt reports the patient 
as still living — nearly six years after oper- 
ation. In one of Homans^ cases the 
tumor was so adherent to the uterus that 
the body of the uterus had to be removed 
also. The case was that of a woman. 

July 8, 1893. 



aged seventy-two, from whom Dr. Hom- 
ans had removed the right ovary five 
years previously, who had remarried after 
recovery from this operation, and from 
whom he now (1877) removed a multilocu- 
lar cyst of the left ovary together with the 
uterus. In December, 1892, he reports 
the patient as living and well. In June, 
1890, Dr. H. Marion Sims operated on a 
patient aged seventy years, removing a 
multilocular cyst of right ovary, weighing 
eight pounds, adhesions being so extensive 
that he was obliged to remove the uterus 
also, and the patient recovered and is re- 
ported as still living in January, 1890. 

As the nature of the tumor is an im- 
portant factor in estimating the results of 
the operation, an examination of the table 
shows that the most frequently occurring 
tumor is the multilocular cyst. Unfortu- 
nately, in a majority of the cases there is no 
histological report of the nature of the 
tumor extirpated. In one instance — a case 
of Dr. Kelly's — a careful microscopical 
examination showed areas of adeno-carcin- 
' oma in the cyst wall ; another cyst was can- 
cerous at base with involvement of the 
'retro-peritoneal glands, while two of the 
multilocular cysts are reported as papillo- 
matous; sarcoma, dermoid, solid tumor are 
noted once respectively, and in seven in- 
stances the cyst is unilocular. The absence 
■of results of microscopical examination in 
some cases makes it impossible to reach 

■ any accurate decision as to the percentage 
of malignancy, although in seven in- 
stances the tumor is stated to be non- 

With regard to the ovary affected, we 
^have the statement in 27 cases, in 10 of 
which the tumor was of the right ovary, 
while in 17 the left was affected. It is in- 
teresting to note that in our list of 100 
'C^ses, 72 of which report on this point, the 
right ovary is involved in 38, the left in 32 

■ c ases (in 2 cases both ovaries being affect- 
»ed). No evidence is, therefore, afforded 

^that either ovary is the more frequent seat 

of disease. 

The time of first appearance of symptoms 
in the majority of our cases shows that the 
tumors were for the most part rapidly 
growing, in 6 instances the observation 
being made less than one year before opera- 
tion, while in 19 the time was between one 
and two years. The remaining 6 cases 
which report on this point give a time 
varying from three to ten years, 

The subsequent history of these cases 
is a point of great interest; and here, too, 
the facts of our table give definite infor- 
mation in many instances. As was stated 
above, 5 patients died within ten days 
after operation. Of 8 cases reported as 
dying subsequently, 4 lived less than a 
year, while 4 others lived from 5 to 10 
years after operation. The cause of death 
in these 8 cases is variously given — pneu- 
monia, heart disease, old age, etc. 

Eighteen patients recovered from the 
operation and are reported as living at 
present — i.e., in January, 1893, when the 
facts for the table were collected. In two 
cases only was this report given less than 
a year after operation. Nine patients 
were alive and well one to three years 
after, and seven have survived operation 
and are still living from three to ten years 
after. Evidently we can draw no con- 
clusion from the after-history of the pa- 
tients against the advisability of operating 
on the aged, in the face of the fact that 
16 of these 38 patients lived from two to 
ten years after the operation was per- 
formed, 12 of this number being alive at 

The facts shown by our statistics sum- 
marized briefly are : 

Eirst, that the operation of ovariotomy 
in the aged presents no essential differ- 
ences from this operation in cases of youn- 
ger years. 

Second, that the percentage of recovery 
from this^ operation in patients over 70, as 
shown by the results of American sur- 
geons, is 86.8 percent., the mortality 13.1 
per cent. 

Third, that the indications and contra- 
indications for ovariotomy in the aged are 
essentially the same as for this operation 
in general. 

What some people call prudence is often 
what others call meanness. 

The Surgeon's Enemies. 

The surgeon's enemies are almost 
always sporeless bacilli, and though some 
of these show great resistance to the ac- 
tion of antiseptics, such as the staphylo- 
coccus pyogenes aureus, the common 
cause of suppuration, it has nevertheless 
been shown that carbolic acid destroys 
these organisms more rapidly than corro- 
sive sublimate. — Listee. 


Society Reports, 

Vol. Ixix 


Forty-fourth Annual Meeting^ held in Milwaukee^ Wisconsin, June 6, 7, 8, and 

9th, 1893. 


Continued Report. 

Chairman^ Dr. James T. Jelks, of Hot 
Springs, Ark. 

Secretary, Dr. Liston H. Montgomery, 
of Chicago. 

The Section was called to order by the 
Chairman, who delivered an address on 


He dwelt upon the plague that afflicted 
Pharaoh and his household to strengthen 
the relationship of syphilis as it existed at 
that time and as it exists to-day. 

Dr. A. J. Ochsner, of Chicago, con- 
tributed a paper entitled 


(1) Intussusception; (2) Volvulus; (3) 
Meckel's diverticulum. 

The first case was that of a boy, aged 
three years, who, a week before coming 
under observation, fell and immediately 
felt slight pain in the cecal region, but of 
brief duration. Occasional pains were ex- 
perienced during the next few days. At 
the end of a week severe spasmodic pains 
were felt in the abdomen, with nausea, 
vomiting, and a constant desire, with in- 
effectual efforts, to evacuate the bowels. 
Intussusception was diagnosticated and the 
diagnosis confirmed by celiotomy. The 
vermiform appendix seemed to have been 
thrown around the ileum, the constric- 
tion thus produced leading to the intus- 
susception. The appendix was removed 
after reduction had been effected. On 
the fifth day the bowels were moved by a 
glycerine and water enema. The stitches 
were removed on the ninth day and the 
wound supported with adhesive strips. 
The pulse and temperature were but 
slightly affected, and the recovery was rapid 
and complete. 

The second case occurred in a man 32 
years of age, who fell into a ditch two or 
three feet deep, experiencing a slight pain 
in the left inguinal region. Two days 
later the abdomen became swollen and 
painful, and there were nausea and con- 
stipation. A globular enlargement could 
be seen in the lower part of the abdomen. 
Purgatives had been administered for twa 
days without effect, except to increase the 
pain. Volvulus was suspected, and an 
operation for its relief undertaken. On 
opening the abdomen the suspicion wa& 
confirmed. The sigmoid fiexure was found 
so distended that replacement within the 
peritoneal cavity was impossible. A rec- 
tal tube was passed, liberating a large 
amount of gas, after which the bowel 
could easily be replaced. After the fifth 
day the bowels were moved daily by ene- 
mata. Complete recovery followed with- 
out incident, the patient being dismissed 
thirty days after operation. 

The third case occurred ia a man aged 
81 years, who, while in apparent health,, 
suddenly developed the symptoms of acute 
shock. There was a sudden severe pain to 
the right of the umbilicus, which was 
thought to be due to the presence of gall- 
stones. An anodyne gave relief for two 
days ; then the abdomen became uniformly 
distended. There were nausea and vomit- 
ing, first of the stomach contents, and 
later of stercoraceous matter. There was 
no point of special tenderness. An oper- 
ation was undertaken, and a loop of small- 
intestine was found to have slipped through 
Meckel's diverticulum. The adhesions- 
were so firm that it was necessary to apply 
double ligatures and cut between them, so^ 
that the condition must have been one of 
long standing. After the operation, un- 
controllable vomiting continued and death 
occurred thirteen hours later, without re- 
action having taken place. Eegret was 

July 8, 1898. 

Society Reports. 


expressed that the stomach was not washed 
out, as this might have relieved the vom- 
iting. Earlier diagnosis and a younger 
age would both greatly have increased the 
chance of recovery. 


Dr. John B. Eoberts, of Philadelphia, 
contributed a paper on this subject, in 
which he entered a plea for the treatment 
of every surgical case on its merits 
rather than by rule. The opinion was ex- 
pressed that many patients are detained in 
bed unnecessarily long on account of frac- 
tures of the bones of the legs, and that 
patients with fractures of the forearm are 
often likewise burdened with cumbersome 
dressings long after the usefulness of these 
had ceased to exist. Sprains and chronic 
joint-affections often demand massage and 
passive motion, rather than continued 
rest. It was held that the habit of re- 
stricting the diet of patients for days after 
an operation is unnecessary, as well as a 
large number of other customs that have 
been taught and practiced for so many 
years that almost no one stops to consider 
whether they are rational or not. 

Dr. John E. Link, of Terre Haute, 
Ind., reported cases affording evidence of 
the surgical immunity of the peritoneal 
viscera. He gave the results of many op- 
erations performed in the most careless 
manner on dogs, and always with recovery 
of the animal. The object was to show 
that, when skilled surgical aid cannot be 
obtained, the family physician should pro- 
ceed to operate in cases of abdominal in- 
juries or other serious acute conditions, 
inasmuch as the peritoneum is much more 
tolerant of invasion than has been gener- 
ally supposed, and the danger of delay in 
operating far out- weighs that to be feared 
from opening the abdomen. Dr. Link 
demonstrated his method of operating on 
dogs, and showed several specimens taken 
from animals previously operated upon. 



Dr. 0. Fenger, of Chicago, read a pa- 
per entitled 


He said that in hydronephrosis or pyone- 
phrosis there must be an obstruction 
somewhere. In many cases of intermit- 

tent discharge, the difficulty is due to ob- 
lique insertion of the ureter into the 
pelvis, and the consequent formation of a 
valve at the point of junction. The fluid 
is prevented from passing until the dis- 
tention and pressure are sufficiently great 
to overcome obstruction, and the accumu- 
lation escapes. Dr. Eenger has operated 
on such a case by splitting the valve and 
stiching its margins apart after opening 
the pelvis. Strictures of the ureter also 
cause hydronephrosis or pyonephrosis. 
They may result from ureteritis or from 
indirect traumatism. A case was report- 
ed in which pyonephrosis developed two 
years after a fall. An operation was per- 
formed, the stricture divided longitudin- 
ally, and stiches passed in the same direc- 
tion as the line of the incision, thus con- 
verting the longitudinal into a transverse 
wound. The appearance of blood in the 
urine for a few days demonstrated the 
patulousness of the ureter. Kecovery was 
complete. The best incision for this op- 
eration is the lumbar one, from the 
twelfth rib to the crest of the ilium, and 
then extended to the middle of Poupart's 
ligament. This gives ready access to the 
upper two-thirds of the ureter. The 
lower third can be reached by sacral re- 
section. The value of relieving obstruc- 
tion to the ureter is shown by the fact that 
after nephrotomy a fistula remains in 45 
per cent, of the cases ; while nephrectomy 
is to be avoided if possible, as the condi- 
tion of the opposite kidney is generally not 
known, and the radical operation may re- 
sult in speedy death from uremia if the 
second kidney is also diseased. 


Dr. J. B. Murphy, of Chicago, followed 
with a paper on this subject, in which he 
said that the function of the gall-bladder 
is to regulate the pressure in the bile 
ducts, as the air chamber does in the 
steam pump. In support of this view, 
reference was made to the fact that the , 
bile is always much more concentrated in 
the gall-bladder than any of the ducts, 
and also that in a very large number of 
operations upon the living subjects, the 
cadaver, and upon animals, the gall-blad- 
der was never found empty in health. 
The pathological conditions of the gall- 
bladder calling for operative interference 
are chiefly cholelithiasis, cholecystitis. 


Society Reports. 

Vol. Ixix 

carcinoma of the head, of the pancreas, 
neoplasms involving the ducts^ carcinoma 
of the gall-bladder and trauma. The op- 
erations, naturally, all necessitate celio- 
tomy. Of 25 cases of simple puncture 
collected, one-fourth terminated fatally. 
This is to be explained by the fact that the 
walls of the gall-bladder are so dense and 
so slightly contractile that the puncture 
opening remains patulous, and thus allows 
the contents to continue to escape. In 
23 cases in which an incision was made 
and drainage provided for, the mortality 
was 18 per cent. Dr. Murphy has had 
made a modification of his anastomosis- 
button, in which one part is two and a 
half or three inches in length, and being 
hollow, allows the bile to escape entirely 
externally to the peritoneal cavity, so that 
it is impossible for any leak to occur. In 
59 cases collected, in which cholecystotomy 
was performed in two sittings, the death- 
rate was but ten per cent. — a very favor- 
able showing. The same operation per- 
formed at one sitting, as advocated and 
practiced by Tait, is a much more serious 
procedure. Of 201 cases operated on by 
this method, 25 per cent, died, and in 
many others a sinus persisted. Incision 
with immediate suture — ideal cholecystot- 
omy — has been practiced a number of 
times. In 30 cases collected there were 6 
deaths — a mortality of 20 per cent. Dr. 
Murphy advises joining the gall-bladder 
with the intestine (cholecysto-enterostomy) 
in all cases in which it is necessary to per- 
form cholecystotomy. This permits of 
complete closure of the abdominal incis- 
ion, and digestion is not impaired by the 
escape of bile externally. Nussbaum was 
probably the first to employ this procedure, 
but on account of the great difl&culty in 
effecting the anastomosis, the operation 
was gradually abandoned. By means of 
the anastomosis- buttons designed by Dr. 
Murphy, the operation becomes a simple 
one that can be quickly performed. 
Eleven cases have been collected. Seven 
have been operated on by Dr. Murphy 
himself ; recovery taking place in all. Two 
other operations mentioned were also suc- 
cessful. The method was demonstrated 
by an operation on a living dog. 






This was the title of a paper read by 
Dr- M. E. Oonnell, of Wauwatosa, Wis. 
The author exhibited specimens and ex- 
plained the operation by reference to dia- 
grams. He said end-to-end approxima- 
tion or lateral apposition may be practiced, 
the latter being the simpler. The opera- 
tion is performed as follows: After 
making the necessary incisions, a suspend- 
ing loop is inserted in the bowel just be- 
yond the ends of the cuts, and 
held by an assistant. A suture, three feet 
long, is made to transfix all of the coats 
of one margin of the wound, and passed 
in the opposite direction through all the 
coats at a corresponding point on the other 
end of the bowel. This is repeated until 
the whole length of one side of the wound 
has been traversed, always leaving a loop 
of an inch or two. 

Then, by turning the bowel over, the 
other margin of the wound is closed by 
passing stitches in the same manner; but 
this time drawing them taut so as to close 
the wound. This having been 
completed, the two ends of the first su- 
ture are pulled upon, and, after the appo- 
sition is accurate and firm, a knot is tied 
in each end. After the second knot has 
been tied both ends are cut loose. 

Dr. E. W. Andrews, of Chicago, had 
used Dr. Murphy's buttons in a recent 
case of strangulated femoral hernia in 
which it became necessary to resect fifteen 
inches of gangrenous intestine. He made 
an end-to-end approximation. The sub- 
sequent course of the case was favorable, 
and there was prompt and satisfactory re- 

Dr. H. 0. Walker, of Detroit, said that 
one of the strongest points in favor of 
performing anastomosis by Murphy's 
method was the short time required to 
do it. 

Dr. Bayard Holmes, of Chicago, read a 
paper entitled 


in which he said that glanders in man is 
of two kinds: (1) acute, in which death 
usually occurs in three or four months, 
and (2) chronic, in which the patient may 
recover after three or four years. In the 
case reported, the patient was a farmer 
twenty-two years old, who had alw^ays en- 
joyed good health. In December, 1889, 
one of his horses became stiff, had a dis- 

July 8, 1893. 

Society Reports. 


charge from the nose aud died in a week. 
The mate of this horse also became sick, 
and had numerous pustules oyer the body. 
In a short time the patient noticed a sore 
on one of his fingers. The affection was 
thought to be a carbuncle. In a short 
time five foci of the disease appeared in 
different portions of the body. There 
was at first sharp, burning pain, like that 
which follows the sting of an insect, and 
deep swelling. At three points sponta- 
neous opening took place. When the 
patient came under observation, it was de- 
cided to remove the disease radically by 
the cautery instead of the knife. The 
diseased area was scraped thoroughly, the 
surface brushed with a strong solution of 
zinc chloride and packed with iodoform 
gauze dipped in a concentrated solution of 
potassium iodide. In all, fourteen differ- 
ent lesions appeared, requiring twenty dif- 
ferent operations. Adenitis occurred but 
once. The diagnosis was confirmed by 
inoculation of animals. 


Dr. Ernest Laplace, of Philadelphia, 
read this paper, in which he said the oper- 
ation consists in ligating the long saphe- 
nous vein at the saphenous opening, and 
the short saphenous vein between the two 
heads of the gastrocnemius. The after- 
treatment consists of rest in bed, elevation 
of the limb, and careful wrapping in cot- 
ton. The patient may be allowed to arise 
in two or three weeks. Seventeen cases 
were reported, in six of which the opera- 
tion was bilateral. All did well, and the 
ten recently heard from remain free from 
their trouble. Cocaine ansesthesia was 

Dr. B. M. Ricketts, of Cincinnati, fol- 
lowed with a paper entitled 


The conclusion arrived at from experi- 
ments on animals was that the operation 
of Mansell was one of the best methods 
so far described. It could be rapidly per- 
formed, and met all of the requirements. 

Dr. Thomas H. Manley, of New York» 
read a paper entitled 


In cases of traumatism of the lower 
limb the author made a plea for more 
conservative surgery. He held that not a 
particle of tissue should be sacrificed that 
would survive. A secondary operation 
was to be preferred, if the patient so de- 
sired, for the cosmetic effect or the greater 
usefulness of the member. 

Dr. I. N. Quimby, of Jersey City, 
agreed with the author to save all tissue 
possible. In 1887, he introduced a modi- 
fication of Pirogoff's amputation, in which 
he does not resect the ends of the tibia 
and fibula, but places the sawn surfaces of 
the OS calcis against the articular surfaces 
of the tibia and fibula. He regarded this 
as very important in the case of children, 
as the epiphysis was thus spared, and the 
growth of the bone not interfered with. 

Dr. Donald Maclean, of Detroit, main- 
tained that the mere removal of the artic- 
ular cartilege would not interfere with the 
epiphysis. He considered Syme's opera- 
tion as the best in this situation and prac- 
ticed it, especially when the operation was 
performed for disease. 

Dr. Summers, of Wisconsin, desired to 
endorse the procedure recommended by 
Dr. Quimby, and declared that a recent 
traumatic surface united better to a serous 
surface than to another traumatic surface. 


By Dr. Joseph Hoffman, of Philadelphia. 
The author said that it was now settled 
that the appendix was situated in the peri- 
toneal cavity, and, therefore, all inflam- 
mations of the process were intra-perito- 
neal. The anatomical relations of the ap- 
pendix were such that a considerable de- 
gree of mobility was permitted, and the 
symptoms of appendicitis, therefore, va- 
ried in different cases. The presence of 
pus was always an indication for operation 
without delay. 


Society Reports. 

Vol. Ixix 

Dr. J. B. Murphy, of Chicago, said he 
would remove the appendix in every case 
as soon as he had made the diagnosis. He 
had operated ninety-five times for removal 
of the appendix with seven deaths, five 
from general peritonitis, which had been 
present before the operation, and two from 

Dr. N. Senn, of Chicago, said we should 
be cautious not to operate without due 
consideration, as the operation might pre- 
sent considerable difficulty. Eemoval of 
the appendix was to be recommended in 
recurrent attacks. 

Dr. Joseph Eansohoff, of Cincinnati, 
contributed a paper entitled 


and reported two cases treated in this way. 
One was a case of bronchial aneurism; the 
other a case of anterior tibial 
aneurism. In each case an inci- 
sion was made over the tumor; the 
vessel traced in both directions; 
two ligatures applied, both above and be- 
low; the artery cut between and the tu- 
mor enuncleated. The following propo- 
sitions were submitted : (1) Extirpation is 
the ideal operation ; (2) in aneurisms of the 
forearm and leg, no other method should 
be employed; (3) in aneurisms that sud- 
denly enlarge, and when rupture seems 
imminent, extirpation should be employed ; 
(4) in recent traumatic aneurisms, the 
vessels should be ligated above and below, 
and if a sac has formed, this should be 
removed; (5) after other methods have 
failed, extirpation should be employed; 
(6) arterio-venous aneurisms should be 
subjected to the same treatment; (7) proxi- 
mal ligation may be performed when the 
age of the patient, the location or other 
causes contra-indicate extirpation. 




By Dr. John A. Wyeth, New York City. 
He advises first to drill two holes in the 
hard palate; pare the mucous membrane 
from the margins of the cleft, and, with 
strong scissors or with delicate bone for- 
ceps, divide the alveolus on the short side 
at about its middle, and slide the anterior 
fragment forward and wire in this posi- 
tion. This closes the anterior part of the 
cleft. The lip may be operated on at the 
same time, or subsequently, as seems best. 


The first paper read was by Dr. Frede- 
rick 0. Schaefer, of Chicago, entitled 


In which he reported 8 cases. These 
cases demonstrated the importance of care- 
fully examining every case of injury and of 
prompt surgical interference in all in- 
stances in which a fracture is detected, 
even if there be no symptoms indicating 
intra-cranial involvement. In one case, in 
a man, fifty years of age, in which there 
was most extensive fracture of the anterior 
fossa of the skull and of the frontal bone, 
the patient walked a distance of a mile to 
his home. There were no symptoms 
whatever of any cerebral disturbance when 
the patient was first seen. Operation was 
advised but refused, and the wound was 
treated antiseptically. 





Dr. E. L. Shurly, of Detriot, read a 
paper on this subject. The author said 
that, although pulmonary cavities had 
been opened artificially occasionally since 
1847, the procedure had only recently 
been recognized as a justifiable one. He 
recommends the additional injection of 
diluted chlorine gas into the cavities at in- 
tervals of three or four days. The gas is 
obtained by half filling a Wolff bottle with 
fresh chlorine water, forcing air through 
this into the pulmonary cavity. 

Dr. J. MacFadden Gaston, of Atlanta, 
contributed a paper on 


in which he summarized as follows : 

1. All penetrating wounds of the thorax 
may be closed hermetically by suture after 
allowing the discharge of fluid blood from 
the opening. 

2. Foreign bodies lodged in the bronchi 
may be removed by incision of the trachea 
at the lowest available point. 

3. Experiments for reaching the bronchi 
through the chest wall afford little en- 
couragement in undertaking operation 
upon the human subject. 

4. Medication as a preventive and cur- 
ative agency in pleuritic effusion is worthy 
of trial before recourse to operation. 

July 8, 1893. 

Society Reports. 


5. Aspiration is indicated when there 
are large serons accnmulations, and like- 
wise in pneumothorax, but cannot be re- 
lied upon for the relief of purulent col- 

6. Partial resection of ribs is attended 
mi}i better results in some cases of em- 
pyema than the complete removal of the 
segments of several ribs. 

7. The excision of a small portion of 
one rib, with- the introduction of drainage 
tubes, has been generally attended with 
good results. 

8. Washing out the cavity of the chest 
is not requisite, except in case of contami- 
nation and decomposition of the contents. 

9. The operation of thoracotomy foj 
abscess and gangrene of the lung should 
be accompanied with antiseptic applica- 
tions and with gauze tamponage. 

10. Tumors of the mediastinum admit 
of interference, but further improvements 
are requisite. 


by Dr. William A. Rodman, of Louisville. 
In this paper the author considered the 
various cysts of the neck, and of these, 
those connected with the thyroid gland 
are quite common. In the treatment of 
such cysts, the speaker said that Kocher 
recommended partial excision of the gland. 
Total excision led to the cachexia strumi- 
priva. In 18 cases of total extirpation 
observed by Kocher, but two failed to de- 
velop the cachexia; while of 28 partial 
excisions, no untoward after-effects were 
exhibited in any of the cases. Lympho- 
mata of the neck were by far the most 
frequently observed. Sarcoma was more 
common than carcinoma. Unless seen 
early, cases of sarcoma of the neck did not 
offer satisfactory conditions for surgical 
interference. The author recommended 
the removal of tuberculous glands of the 
neck, as the infection spreads through the 
lymphatics and involves other glands. 

Dr. Joseph Price, of Philadelphia, read 
a paper entitled 




When the patient cannot stand a pro- 
longed operation, incision and drainage 
should be employed. If there remains 
any secreting structure of the kidney, it 
is well to perform nephrotomy, as the pos- 

sibility of a horseshoe kidney should be 
borne in mind. In this event, removal 
would result in speedy death from uremia. 
In the surgery of the kidney, as else- 
where, the simplest procedure that will 
meet the indications should be employed. 
Dr. Price related that he had performed 
incision, irrigation, and drainage in seven 
cases without a death. 


by Dr. W. Van Hook, of Chicago. He 
said that the fact that the ureter was 
sometimes injured during abdominal and 
pelvic operations led him to devise a 
means of uniting the divided ends. One 
end is lighted, a longitudinal incision 
made above the ligature, and, by means of 
two threads, the other end is invaginated 
into the longitudinal incision. The op- 
posed portions are carefully united, and if 
desired, covered with a flap of peritoneum, 
to make the union more perfect. It is 
recommended, when it is desired to 
implant the ureter in the bladder, that the 
nreter be first stitched in the abdominal 
wound, and later, the bladder stitched as 
high as possible in the abdomen; and 
when adhesions have become firm, the 
ureter may be implanted in the bladder- 
with considerable hope of entire success. 
It necessitates three sittings to complete 
the operation, but the results justify the 
method. The author advises against im- 
plantation of the ureter into the rectum. 
Other objections were the occurrence of 
ureteritis and pyelitis. 

The speaker presented the following 
general considerations : 

The extra-pelvic portion of the ureter 
is most readily and safely accessible for 
exploration and surgical treatment by the 
retro-peritoneal route ; hence all operations 
upon the ureters above the crossing of the 
iliac arteries should be performed extra- 
peri toneally, except in those cases in 
which the necessity for the ureteral oper- 
ation arises during celiotomy. The intra- 
pelvic portion may be reached by incision 
through the ventral wall, the bladder, the 
rectum, the vagina in the female, or the 
perineum in the male. The nreter is not 
only exceptionally well protected from in- 
jury, but by its elasticity and toughness 
resists violence to a remarkable degree. 
The histology of the ureters furnishes 
most favorable conditions for the healing 
of wounds. Longitudinal wounds of the 


Society Reports. 

Vol. Ixix 

ureter at any point lieal without difficulty 
in the absence of septic processes and 
under the influence of ample drainage. 
In all injuries^ when the urine has been 
septic before operation, or when the wound 
is infected during the operation, drainage 
must be effected posteriorly. The chemi- 
cal composition and the reaction of the 
urine should be studied in all injuries 
of the ureter, the urine being rendered 
acid if possible and the specific gravity 
kept low. The pelvis of the ureter is, 
ccBteris paribus^ the most favorable site 
for wounds of the ureter, as scar contrac- 
tion is not likely there to be productive 
of ill results. In aseptic longitudinal 
wounds of the ureter occurring in the 
course of celiotomy, suture may be prac- 
ticed as recommended by Tuffier, and the 
peritoneum protected by suture. Trans- 
verse wound of the ureter involving less 
than one-third of the entire circumfer- 
ence of the duct, should be treated by 
free extra- peritoneal drainage and not by 
suture. In transverse injuries in the 
continuity of the ureter involving more 
than one- third of the circumference of 
the duct, stricture by subsequent scar 
contraction should be anticipated by con- 
verting the transverse into a longitudinal 
wound and introducing longitudinal su- 
tures. In complete transverse wounds of 
the ureter at the pelvis, sutures may be 
used if the line of union be made as 
great as possible. In complete transverse 
injuries of the ureter in continuity, union 
should not be attempted by sutures. In 
complete transverse injuries of the ureter 
in continuity, union with subsequent scar 
contraction may be obtained by lateral im- 
plantation. In complete transverse inju- 
ries of the ureter very close to the bladder 
the duct may be implanted, but with less 
advantage into the bladder directly. 

In transverse injuries of the ureter with 
loss of substance, the following conclu- 
sions were formulated : 

1. At the pelvis of the ureter, contin- 
uity may be restored by Kuster's method 
of suture, provided the several ends can be 

2. Rydygier's method of ureteroplasty 
in such injuries should be tried, if sutures 
cannot be utilized. 

3. The primary operation should at 
least fix the ends of the tube as nearly to- 
gether as possible. In both intra-peri- 
toneal and retro-peritoneal operations the 

urethral ends can be approximated, even 
after the loss of about an inch of sub- 

4. The use of tubes of glass and other 
materials for the production of channels, 
to do duty in place of destroyed ureteral 
substance, is rarely successful, and even 
if temporarily successful the new duct is 
almost sure to be choked by scar contrac- 

The implantation of the cut ends of a 
ureter into an issolated knuckle of bowel 
is objectionable : {a) Because the bowel is 
not aseptic ; {h) because the operation is 
dangerous. In injuries of the portion of 
the ureter within, the pelvis, with loss of 
substance, the ureter should be treated as 
follows : If possible the continuity of the 
uterer should be restored by lateral im- 
plantation. If this is not possible, the 
ureter in vaginal operations, particularly 
in vaginal hysterectomy, should be sutur- 
ed to the base of the bladder, with a 
view of future vesical implantation or for- 
mation of a vesico-vaginal fistula with 
kolpokleisis. In injuries to the pelvic 
ureter during celiotomy, when the contin- 
uity cannot be restored, and when vesical 
or vaginal implantation cannot be effected 
in the female, or vesical implantation in 
the male, the proximal extremity of the duct 
should be fastened to the skin, at the 
nearest point to the bladder arch. In 
such cases, as well as in ventral ureteral 
fistulae due to other causes, the bladder 
may be distended and sutured to the ab- 
dominal peritoneum and muscles as high 
as possible, and at a second operation the 
ureter may be implanted extra-peritone- 
ally into the bladder. If the ureter will 
not reach the bladder, a flap of bladder 
wall may be cut out extra-peri toneally and 
reflected upward to meet the ureter and 
form a tube. It is legitimate under such 
circumstances to try Eydygier^s method. 

Implantation of one or both ureters into 
the rectum is absolutely unjustifiable un- 
der all circumstances, because: {a)^ the 
primary risk is too great; (&), there is 
great liability to stenosis at the point of 
implantation ;(c), suppurative uretero -pye- 
lonephritis is almost absolutely certain to 
occur. Ligation of the ureter to cause 
atrophy of the kidney is unjustifiable. 





July 8, 1893. 

Society Reports. 


by Dr. Henry 0. Marcy, of Boston. 

The author said, continued experience 
and observation had confirmed the opinion 
formed many years ago, that the army of 
truss bearing sufferers will constantly grow 
less and less, as cases of hernia are sub- 
jected to proper operative procedures. 
The mortality of radical operations for 
hernia in good hands was very small, and 
the proportion of cures was very credit- 

Dr. Donald Maclean, of Detroit, fol- 
lowed with, a paper entitled: 


He reported two cases, and on account 
of the position of the aneurism, and the 
numerous and important branches that 
the femoral artery gives off, he deviated 
from the treatment usually followed and 
ligated the external iliac artery. Both 
cases recovered. 

Dr. D. J. Hayes, of Millwaukee, re- 
ported two cases in which he had operated 
for the establishment and maintenance of 
a urethra above the symphysis pubis in 
chronic prostatic obstruction. The speak- 
er paid a compliment to Dr. Hunter Mc- 
Guire, who first devised the operation for 
this condition. The procedure was to be re- 
commended on account of its ease of per- 
formance and the very satisfactory results. 




This was the title of a paper read by 
Dr. H. C. Dalton, of St. Louis. One 
case termimated fatally on account of 
operation being delayed too long. The 
other cases made satisfactory recoveries. 
The author urged immediate operation in 
such cases. 

Dr. Howard A. Kelly, of Baltimore, 
read a paper on 


He exhibited several photographs, show- 
ing the incision and various steps of the 

Dr. I. N. Quimby, of Jersey City, re- 
ported the case of a boy in which, a few 
hours after receiving a blow upon the 
head by a stone, convulsions supervened. 
It was decided to trephine after consulta- 
tion. A button of bone was removed and 

the internal table was found much de- 
pressed and splintered. The patient made 
a complete recovery. 


Dr. A. Dallas, of New York City, con- 
tributed a paper entitled : 


in which he is said he devised a new form 
of truss, Avhich consisted of a covered 
steel spring which was adapted to the 
body over the iliac crests, the anterior arm 
descending almost vertically and covering 
the entire inguinal canal. Perfect reten- 
tion with the least pressure, comfort in 
wearing, and stability in proper position 
were the advantages claimed for the truss. 
The author recommends the employment 
of hypodermatic injections of morphine and 
atrophine every 15 minutes until the patient 
is comfortable, in cases of strangulated 
hernia, these injections to be made about 
the hernia. Should operation finally be- 
come necessary, it may be performed un- 
der morphine narcosis. A modification 
of MacEwen's operation was advised for 
the radical cure. 

Dr. Ernest T. Tappy, of Detroit, read 
a paper entitled, 


The patient was a man of 40 years of 
age, with a strangulated hernia for five 
days, and when he first came under the 
doctor^s care, the sac and hernia were gang- 
renous. The sac had already been opened 
by a physician. One week after admis- 
sion, when a line of demarkation had 
formed between healthy and unhealthy 
tissue, the adhesions were separated, a 
fresh section made, and end-to-end ap- 
proximation of the bowel performed and 
maintained by suture of the mesentery, 
mucous membrane, and of the serous sur- 
face. There was complete recovery with- 
out complication. 

Dr. A. B. Kirkpatrick, of Philadelphia, 
described a new applicator for introduc- 
ing medicaments into the urethra, uter- 
us, and rectum, which is made of alumi- 
num, silver, or hard rubber, and consists 
of a cylinder of about 8 inches long, with 
an accurately adjusted piston. The an - 
thor had found that a powder of iodoform, 
boric acid, morphine, and atropine, intro- 
duced by this applicator, was almost a 
specific in acute gonorrhea. 


Society Reports. 

Vol. ixix 


Dr. Joseph B. Bacon, of Chicago, read 
a paper on this subject. The operation 
consists in performing celiotomy in the 
Trendelenburg position. The rectum is ex- 
posed and the male half of the Murphy 
button is introduced into the sigmoid end, 
and the female half introduced on a staff 
through the anus and to the proper posi- 
tion in the rectum, an anastomosis thus 
being made around the strictured portion. 
In the application of the button, the por- 
tion in the sigmoid is sutured, but in the 

rectual half, a small opening is made in 
the bowel wall, and the cylinder crowded 
through and the button clamped. 

Dr. W. P. Verity, of Chicago, read a 
paper on 


which was illustrated by drawings. 

Dr. E. A. Tracey, of Boston, described 
a new material for surgical splints and 
jackets, and a method of applying it. 
Wood-pulp is the material that he em- 
ploys, prepared in sheets, and from them 
suitable patterns are cut. 


Dr. Charles C Stockton, Buffalo, N. 
Y., Chairman. 

Dr. George W. Webster, Chicago, 111., 

The first paper read was the Chairman's 
Address by Dr. Stockton, entitled 


He said that a few years ago endocardi- 
tis was considered a simple inflammation 
of the lining membrane of the heart. 

After Osier's lectures in 1885, it be- 
came clear that the disease was sometimes 
infectious, and endocarditis was spoken of 
as acute, chronic and malignant and ul- 
cerative. In relation to rheumatism, ref- 
erence was made to the chemical theory 
of Prout and the nervous theory of Mit- 
chell, but the disposition was manifested 
to accept the germ theory as being more 
rational. From the known facts it was 
concluded that endocarditis may, under 
favorable conditions, arise from any one 
of a multiplicity of special causes, and 
that its course may be as variable as the 
causes are dissimilar. Of the two classes, 
malignant and non-malignant, the paper 
dealt with the former. Ulcerative endo- 
carditis depends upon the presence of a 
micro-organism that generally attacks the 
endocardium as the result of some pre- 
ceding affection. Some forms of micro- 
organisms have the apparent faculty of 
inducing endocarditis in the healthy or- 
ganism, and are regarded as special to 
this form of disease. Weichselbaum has 
discovered four such organisms ; Fraenkel 

and Saenger haxe described one, and Lion 
and G-irode still another. The bacillus coli 
communis has, in some cases, been the ac- 
tive agent in the development of this dis- 
ease. A case has been reported by Dr.W.T. 
Howard, Jr., in the Johns Hopkins Hospi- 
tal Bulletin for April, 1893, in which ma- 
lignant endocarditis was found to depend 
upon a bacillus having morphologically 
and culturally the characteristics of the 
bacillus of diphtheria, although the pa- 
tient presented no history of having had 
diphtheria. Different micro-organisms 
produce different pathologic chemical re- 
sults. Some organisms invade the mitral 
and some the aortic valve by preference. 
Careful observations show that the main 
valves are first invaded. According to 
Saenger, the valves in a pathologic state 
contain vessels in which colonies of bacte- 
ria are found, so that the process may be 
primarily intravalvular ; but in many cases 
the disease appears upon the free surface 
of the valves. 

In Taylor's series, in 11 of 53 cases of 
endocarditis the lesion occurred on the 
right side. Lion suggests that aerobic 
bacteria grow best in the arterial blood of 
the left side, and anaerobic in the carbon- 
ized blood of the right heart. The opin- 
ion was expressed that cases of malignant 
endocarditis recover, .and that it is a mis- 
take to apply the term simple endocarditis 
to all cases that have a favorable termina- 

Dr. J. G. Truax, of New York City, 
had seen 13 cases of ulcerative endocardi- 
tis which were fatal. Most of his cases 

July 8, 1893. 

Society Reports. 


had articular rheumatism. In two- thirds 
of them a mistake in diagnosis was made, 
and the true condition made known by 

Dr. Henry D. Didama, of Syracuse, 
dwelt upon the experiments of Kichard- 
son, who, he said, produced not only ar- 
ticular rheumatism, but also endocarditis, 
by injections of lactic acid. 

Dr. H. J. Herrick, of Cleveland, Ohio, 
maintained that endocarditis was a secon- 
dary form of disease, and that if the blood 
was in perfect condition, there could be no 
endocarditis. Treatment should be di- 
rected to the predisposing cause. 


by Dr. W. H. AYashburn, of Milwaukee, 
Wis. The author said that the death-rate 
of pneumonia was gradually on the in- 
crease in this country under the present 
methods of treatment. As long as physi- 
cians were unable to destroy the materies 
morli of the disease, all efforts at treat- 
ment were but palliative. Support of the 
nervous system and elimination of the 
specific poisons of the disease and the 
products of retrograde metamorphosis 
were the indications for treatment. Al- 
cohol was to be regarded not as a stimu- 
lant, but as a sedative. 

Dr. K. H. Babcock, of Chicago, con- 
tributed a paper entitled 


in which he said that, owing to its insidi- 
ous onset, purulent pleurisy was frequent- 
ly overlooked. He would especially call 
attention, as supporting this belief, to the 
vague and general manner in which the 
disease was treated by most of the text 
books. In many instances the disease was 
secondary to some pre-existing affection, 
especially croupous pneumonia and influ- 
enza. If due to the presence of the pneu- 
monia coccus, there was a great tendency 
to spontaneous evacuation through the 

He recognized four types of empyema. 
The prognosis in the form of pneumonia 
due to the pneumonia coccus was good. 
Such cases usually yielded to simple punc- 
ture and drainage. The other forms in- 
dicated a graver prognosis, and required 
more active surgical intervention. 

Dr. W. A. Batchelor, of Milwaukee, 
said the treatment of empyema should 
consist in incision and drainage. Many 
cases could be cared by aspiration, and he 
believed that bacteriological investigations 
of pleurisy would lead to better methods 
of treatment. 

Dr. Martine, of New York, held that 
the reduction in the pulse rate in cases of 
pleurisy would prevent empyema. 

Dr. George W. Webster, of Chicago, 
had treated seven cases of empyema, in 
persons ranging in age from 3 to 40 years, 
within the last sixteen months, by wash- 
ing out the pleural cavity with a saturated 
solution of boric acid. All of the cases 



by Dr. J. M. Anders, of Philadelphia. 
Attention was directed to the influence of 
the various seasons of the year upon the 
disease. The author collected a large 
number of cases from hospital and private 
practice, and after careful study found 
that the largest number of cases occurred 
in April, and that from April to August 
there was a gradual decrease in the num- 
ber. More than one-half of the cases 
collected occurred under 30 years of age, 
and these were largely between the ages 
of 20 and 30. Of 1787 cases, 1239 were 
males and 548 females. Slight wounds 
and contusions of the face and head were 
exceedingly common as starting points of 
the disease. In only 7.8 per cent, was 
the affection secondary to chronic disease. 
The author said that the average duration 
of the affection in over one thousand 
cases was twenty-five and one- tenth days ; 
that if the individual was in an enfeebled 
condition the duration was longer. Ee- 
lapses occur in about ten per cent, of all 

Dr. H. A. Hare, of Philadelphia, said 
that erysipelas was quite frequent in cases 
of pronounced nasal and buccal lesions. 
In typhoid fever, for example, such 
lesions afforded entrance to the specific 
organisms of the disease. 


by Dr. Max Einhorn, of New York City. 
One of the objects of the paper was to 
point out the great difficulty of making a 


Society Reports. 


correct diagnosis of abdominal disease, 
more particularly in the case of the stom- 
ach, which was the organ most frequently 
diseased. The apparatus exhibited by the 
author consisted of a soft rubber tube, to 
which v\^as attached an Edison lamp. The 
apparatus can be introduced into the 
stomach with no more diflQculty than is 
required in introduding the ordinary 
stomach tube. The patient must be in a 
fasting condition, and immediately before 
the passage of the tube, should be given 
one or two glasses of water. The author 
exhibited two patients and demonstrated 
the working of the apparatus. 

Dr. John Aulde, of Philadelphia, al- 
luded to the value of translumination in 
the diagnosis of laryngeal disease, particu- 
larly in young subjects, and said it might 
be of value in gynecic and rectal disease 
and abdominal surgery as an aid in diag- 

Dr. Joseph Eichberg, of Cincinnati, 
followed with a paper entitled 


The true pathology of sunstroke had not 
yet been determined, although it was 
known that there occurs a disturbance of 
the heat regulating center. The progno- 
sis was influenced by the degree of cere- 
bral activity. Treatment consists in re- 
duction of the temperature by external 
applications of cold, and the administra- 
tion of digitalis or the hypodermic injec- 
tion of digitalin to stimulate the heart 


by Dr. E. E. Eoss, of Buffalo, N. Y. 
The author did not dwell on all that is 
conveyed by the term thermic fever, but 
confined his remarks to sunstroke. He 
said that high degrees of temperature 
might be borne if the air was dry, be- 
cause he considered sunstroke very rare in 
dry hot countries, and that those who had 
clean skins and a good vasomotor system 
were less prone to it. The prophylactic 
treatment consisted in cleanliness and the 
avoidance of mental and physical exhaus- 
tion. He looked upon antiseptics as use- 
less and dangerous, for the reason that 
they may produce heart failure and exert 
a destructive influence upon the blood cor- 
puscles. An important point in treat- 
ment was the reduction of the tempera- 

ture. He thought it was wrong to pack 
the patient ia ice, on account of the shock 
that results. The temperature of the bath 
should be 45 or 50, and the patient should 
be immersed for two or three minutes, the 
head being cooled as rapidly as the body. 
He recommended rubbing the skin with a 
coarse towel, and having the process re- 
peated. Atropine, sulphuric ether, cam- 
phur and strychnine he uses according to 
circumstances. In the case of convales- 
cents a diet of liquid and farinacious food 
should be adhered to. 

Dr. Hare, of Philadelphia, was inclined 
to doubt that the danger in sunstroke 
was due to conbustion, believing that it 
was due to the change that takes place in 
the nervous system. 

Dr. N. S. Davis, Jr., of Chicago, read 
a paper entiled 


in which he advised in the treatment the 
use of Clemens^ solution, except in the 
more advanced cases. Unless the desired 
therapeutic effect was obtained before, the 
dose should be increased to toleration. 
Doses of 6 or 8 minims were usually suf- 
ficiently large. The use of arseniate of 
strychnine had proved efficacious in his 
hands. He had tried pancreatic extracts, 
but had found them of doubtful value. 

Dr. Didama, of New York, cited a case 
in which treatment with pancreatic ex- 
tract was entirely useless. 


by Dr. James W. Putman, of Buffalo. 

The author first considered the 
part played by heredity in a given 
case of headache, and secondly dwelt upon 
the personal history as regards syphilis, 
dyspepsia, etc. After the above had been 
considered, the history of the headache 
should receive attention, when, and under 
what circumstances it came on. The 
character of the headache itself was then 
to be observed, its periodicity, location 
and characteristics. The author then dis- 
cussed the anemic and congested classes 
of headache, together with the methods 
of treatment. He said that reflex head- 
ache from eye-strain was common, but 
oculists failed to afford relief owing to 
imperfect correction of the ocular defects. 

Dr. J. T. Whitaker, of Cincinnati, said 
that eye strain was not such an import- 
ant factor as a great many physicians had 

July 8, 1893. 

Society Reports, 



by Dr. E. D. Ferguson, of Troy, N. Y. 

The author said that the 15 or 20 cases 
that had come under his care since a pre- 
vious report had markedly improved un- 
der treatment with strophanthus, and 
there had been no relapses. He recom- 
mends for the initial dose 8 or 10 drops, 
three times daily, but the dose varies in 
different cases. 

Dr. Hare, of Philadelphia, said he had 
never found strophanthus to act well, but 
that occasionally it causes severe diarrhoea. 

Dr. Anders, of Philadelphia, said that 
when strophanthus was used alone it did 
not give good results. If arhythmia ex- 
isted however, strophanthus and digitalis 
combined regulated the action of the heart 
much better than either of the drugs when 
used alone. 


was the title of a paper read by Dr. Charles 
Denison, of Denver, in which he did not 
advocate the insurance of invalid risks, but 
believed that the time would come when 
a better understanding of the varying 
longevities of invalids might lead to a 
knowledge of their insarability. The 
author believed that latent tuberculosis 
was the cause of more failures in health 
than was usually supposed, and urged the 
employment of systematic safeguards 
against accepting such lives on an equal 
footing with selected healthy risks. 

Dr. John H. Hollister, of Chicago, in 
a paper entitled 


accepted Koch's bacillus as the clause, and 
said that one of the most important prob- 
lems was to prevent the transfer of this 
organism from one person to another. A 
certain means of safety was the steriliza- 
tion of everything coming from the sick. 
Opium was now repudiated in the treat- 
taent. Hypodermic injections of thymol 
had proved very successful. Of all drugs 
perhaps there was no one more highly ex- 
tolled than tannic acid, given by rectal 
injection along with large amounts of 

Dr. J. T. Whittaker, of Cincinnati, 
Ohio, contributed a paper on 


The speaker first set forth the reason 
and methods of its action. Human tuber- 
culosis differed from laboratory tuberculo- 
sis. Invasion by micrococci, he said, was 
often secondary to the tuberculous. As a 
diagnostic agent, tuberculin was of the 
utmost service and certainty. In incipi- 
ent cases it was valuable as a therapeutic 
agent, and in other diseases when the ex- 
istence of tuberculosis was masked by un- 
expected symptoms. 

In the discussion. Dr. Denison, of Den- 
ver, said he often used tuberculocidin in 
preference to tuberculin. As a diagnostic 
agent he especially commends its use. 


The first paper read was by Dr. Henry 
D. Didama, of Syracuse, entitled 


In the first place saliva is an excellent 
substitute for olive oil, glycerine, cosmo- 
line or other substance as a lubricant for 
catheters. Although containing bacteria, 
saliva is not septic and is always at hand. 
Second, in preparing hemorrhoids for in- 
jection he anaesthetizes by means of ether 
or the A. C. E. mixture, and follows by 
digital dilatation of the anus. He then 
brings down the hemorrhoids, ligates those 
with small pedicles, tying with a bow knot, 
and then injects the material to be used. 
Third, he recommends the following facile 
reduction of prolapsed hemorrhoids: The 
patient is placed on his back with his 
knees drawn up. Cocaine is applied to 
the hemorrhoids if tender. These are 
then thoroughly lubricated with vaseline, 
and with the tips of two or three fingers 
pressed up while the patient at the same 
time is directed to bear down. The hem- 
orrhoids readily slip up into the bowel. 
The patient himself can perform this op- 
eration without the aid of a second person. 
Fourth, for the ready relief of lumbago, 
the author has for ten years or more em- 
ployed large dry cups over the entire lum- 
bar region. Four cups are applied at once, 
and the application is repeated. In fifteen 
minutes the pain is entirely gone. 

In the discussion of the paper Dr. Frank 
Billings, of Chicago, said the patient was 
in constant danger of infection from the 
use of saliva as a lubricant. He believes 
that saliva frequently contains pathogenic 
and pyogenic bacteria. 


Society Reports. 


Dr. Charles Denison, of Denver, said 
there was danger of transmitting tubercu- 
losis by the saliva when used as a lubri- 
cant. He also believes that it frequently 
contains tubercle bacilli. 

Dr. John Aulde, of Philadelphia, laid 
stress upon the rheumatic origin of lum- 
bago." He recommended the use of the 
iodide of potassium and the salicylates, as 
well as the faradic currents. 

Dr. Joseph Price, of Philadelphia, 
considered appendicitis one of the most 
troublesome conditions met with by both 
gynecologists and abdominal surgeons. 
lie takes the ground that the condition is 
purely a surgical one, and advises opera- 
tive interference in every case. 

Dr. Whittaker, of Cincinnati, pre- 
ferred the word typhlitis to appendicitis, 
and said that no physician would object to 
operation in cases in which ulceration w^as 

Dr. Joseph Hoffman, of Philadel- 
phia, said there was a possibility of a case 
of appendicitis getting well without treat- 
ment, either medical or surgical, but con- 
valescence was prolonged under such cir- 

Dr. L. S. McMurtry, of Louisville, 
maintained that many cases of appendici- 
tis were reported in the mortality lists as 
peritonitis, more particularly those occur- 
ring in males. 

Dr. J. B. Murfree, of Murfreesboro, 
Tenn., contributed a paper on 


in which he said that the greatest num- 
ber of cases occur between the ages of 
three and twelve, and but very few in in- 
fants. The disease may be transmitted 
by cows, and the period of incubation is 
from two to five days. The prognosis was 
always unfavorable. In the treatment few 
remedies are of much avail, and none is 
specific. Isolation and disinfection must 
be absolute. Antiseptic mouth washes, 
astringent gargles, the swallowing of ice, 
pepsin, trypsin, etc., to destroy the mem- 
branes; tincture of ferric chloride for the 
blood ; mercuric chloride, alcoholic stimu- 
lants, especially large and frequent doses 
of whiskey, constitute a useful method of 

Dr. E. J. C. Minard, of Brooklyn, 
followed with a paj^er on 


The diagnosis of the condition is not 
always easy. The author advised early 


by Dr. Charles W. Purdy, of Chicago. 

The remarks of the author were con- 
fined mainly to the consideration of glycos- 
uria, for the quantitative determination 
of which he proposed a new test. The 
test solution consists of copper sulphate, 
48 grains ; pure potassic hydrate, 144 
grains; strong amxmonia,U.S.P.,9 ounces; 
glycerine, 6 drachms; distilled water, 20 
ounces. It was said to be stable and re- 
liable. Some of the blue solution is placed 
in a vessel and the urine is dropped in 
from a buret until the blue color disap- 
pears, when the amount of sugar present 
may be estimated. 


Dr. H. A. West, of Galveston, Tex., 
contributed a paper entitled 


in which he directed attention to the difli- 
culty of ascertaining after death the ex- 
act morbid condition that was the imme- 
diate cause of death. Lowering of in- 
dividual vitality as a result of fa- 
mine, over-work, and intemperance 
is one of the main predisposing causes of 
various morbid condititions. A wide- 
spread disobedience of sanitary laws is the 
common^origin of most of our epidemic 
diseases. In all acute infectious diseases 
there is a great tendency to involvement 
of the respiratory organs, and especially 
to croupous and catarrhal pneumonia. 
Cardiac disease is usually indicated by 
symptoms referrable to other organs, as 
dyspnoea, digestive disturbance, intesinal 
or renal derangement. Derangement of 
the function of one organ will give rise 
to modification of associated functions 
elsewhere. If the liver be primarily in- 
volved there occurs stasis of the entire 
portal system, with gastric and intestinal 
catarrh, constipation or diarrhoea, jaun- 
dice, etc. Inherited diatheses predisposed 
to the development of tuberculosis. Scrof- 
ulous and gouty individuals are subject to 
tuberculosis and lithemia respectively. 

Julv 8, 1893. 

Society Reports. 


Dr. Charles Denisou, of Denver, 
directed attention to the association of 
fibrosis with tuberculosis. He believes 
that the so-called tubercles aie the vaults 
in which nature imprisons the tubercle 
bacilli to prevent their multiplication. 

Dr. X. C. Scott, of Cleveland, took 
the position that disease was not inherited ; 
that a certain state or condition that fa- 
vors the contraction or developement of 
certain diseases may be transmitted from 
parent to child. As long as the general 
system was in a good condition the indi- 
vidual posesses a certain degree of immu- 

Dr. G-eorge W. Webster, of Chicago, 
maintained that syphilis could be trans- 
mitted by heredity. 


by Dr. J. H. Kellogg, of Battle Creek, 
Mich. In this paper the author described 
a new method of analyzing the stomach 
fluids, and proposed a new classification of 
gastric diseases functional in character. 

Dr. Charles Dennison, of Denver, ex- 
hibited a new syringe for the injection of 
tuberculin, which he considered much 
better than the one usually employed. 
The syringe is marked in minims on one 
side, and on the other milligrams. The 
author uses a one per cent, solution for 
doses under 20 milligrams, and a ten per 
cent, solution for doses over 20 milli- 

Everybody Has Seen Her 

Do you know the doleful person ? asks 
the Omaha World Herald. She, for the 
doleful person is almost always a woman, 
is always a good neighbor in health, and 
tries to be neighborly in sickness. But 
she makes a miserable failure at the latter. 
You know how she acts. Don't you re- 
member the last time the baby was sick ? 
After you had watched by the little one^s 
bed day after day and night after night, 
and watched the roses fade from the little 
one's cheek, and saw the little one's form 
waste away? And don't you remember 
how she tried to cheer you up with a one- 
sided conversation, something like this : 

^' Why, Mrs. B — , how much worse the 
baby looks this morning. She looks just 
like Sarah Jones' baby did the night be- 
fore it died." 

'^ Gracious! I never saw a child so 
wasted away as Sarah's was, except yours. 
We just done everything for the child, but 
it wasn't no use." 

" I never will forget how Sarah took on 
at a funeral !" 

And the doleful neighbor suddenly re- 
members that she has to run back home to 
'^seta sponge," and when she goes you 
hope she will never return. You look 
again at the suffering babe and feel that 
your heart must surely break. 

But suddenly there is a knock at the 
door, and in comes the — well, sun-beam 
neighbor, is as good a name as any. She 
was over the evening before and quietly 
and unobtrusively helped to do so many 
needful things, and when she left, she 
left a word of cheer. And when she 
comes this time she says something like 

' ' Why, how much better the baby looks 
this morning!" 

And don't you remember what a bright 
gleam of hope crossed your mind? 

" I never saw a child improve so much 
in so short a time before. I am sure the 
baby will soon be well." 

And then the sun-beam neighbor re-ar- 
ranges the bed, adjusts the blinds, tells 
you she will call again in a few hours, and 
hurries home. 

Honest, now, didn^t she leave a confi- 
dent feeling behind her? She felt better 
and more hopeful. Baby, even, seemed 
to rally under the words ; and when at last 
the little one was playing around your 
knee again, didn't you think of the words 
of the sun-beam neighbor? 

The doleful neighbor has frightened 
more mothers to death, buried more babies 
and caused more tears than all the plagues 

She should be suppressed. 

The man who never praises hi^ wife de- 
serves to have a poor one. 

Masturbation, according to Prof. Par- 
vin, is of rare occurrence in the female 
sex, the percentage being only about 
three- tenths of one per cent., whilst 
among the male sex it is about three per 

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Saturday, Jui^y 8th, 1893. 



The address of Mr. Ernest Hart, of 
London, before the American Medical 
Association at its recent meeting, demands 
the attention of the whole medical fra- 
ternity. With startling clearness, he 
shows the relation of Cholera to the water 
supply and presents a mass of evidence 
that cannot be put aside or argued away. 
London, with its enormous population, 
and with its water supply divided between 
several companies, each drawing from a 
different part of the stream, presents an 
experiment which it would be hard to du- 
plicate. The lesson is plain and the 
words of the text are written in human 
lives, sacrificed silently, without the 
knowledge that they were yielded up for 
any great cause, without the glory of war, 
without the religious enthusiam of the 
martyr ; and yet they were martyrs in a cause 
greater than that for which men have 
fought and suffered — the prevention of 
disease and plague. 

Medicine is only now coming out of the 
mist and darkness of the mediaeval age and 

is only now grasping the idea that plagues 
are preventable. The old notion that 
they were beyond human control, that 
they were due to a diabolical agency 
against which it were folly to struggle with 
any weapon; or the later vague theory 
that they were due to a subtle miasmatic 
influence as uncontrollable as the wind on 
which it was borne, is giving way to the 
clearer light of scientific research and 
now we know that it is man himself, not 
the devil, not any breath of wind, to which 
we must look for the cause of pestilence. 

When a great epidemic threatens, the 
cry goes up from the press of the land, 
medical and lay, for clean streets, clean 
houses and pure water, but after the dan- 
ger is over there is only too much prob- 
ability that the press will be silent and, like 
faithless sentries, sleep till the footsteps 
of the hostile army grow so loud that 
even the deaf sentry must wake. In an 
army, with the enemy within marching 
distance, such a guard would be unknown. 
Why should it be so in medicine, where 

July a 1893. 



the fight is not against a human foe but 
against a foe that is all the more deadly 
because unseen and sleepless. 

If cholera had reached our city, and 
the deaths had amounted to anything like 
the ratio that there has been from diph- 
theria during the past winter, the town 
would have been deserted and the people 
panic stricken. But typhoid fever and diph- 
theria are diseases which we have gotten 
used to and take as a matter of course ; 
perhaps, as with the diphtheria, quaran- 
tining those suffering with the disease and, 
ostrich-like, burying our heads in the 
sand of a quarantine, thinking that we are 
safe. Of what use is quarantine while the 
source of the disease, filth, is allowed to 

At one time the northwestern part of 
the city was a hot-bed for typhoid fever, 
and the hospitals in that section were full 
to overflowing with cases of the disease. 
The cause was not far to seek. That por- 
tion of the city was supplied with water 
from the Delaware, while the rest of the 
city received its water from the Schuylkill. 
The Delaware is a tidal stream, the sewage 
of the city empties into it; and, although 
the inlet for drinking water was above the 
•outlet for sewage, the supply was polluted^ 
and lives were lost in consequence. With 
the change of supply the typhoid almost 
wholly ceased. 

The great illustrations of the value of 
preventive medicine come from the cities, 
for there men are herded together, and 
the danger of infection is greater. But 
how often does it happen that typhoid 
breaks out in the farmer's family — the re- 
sult of neglect of sanitary laws. The 
people are hard to convince, and it is only 
when the matter is brought home by some 
terrible lesson that they will hear. Too 
often the patient says, " My grandfather 
•drank from this well, and what was good 
.enough for him is good enough for us," 
forgetting all the while that the commu- 
nity has increased in numbers, and what 
was a lonely farmhouse in the midst of 

broad fields has become the centre of a 

People love liberty, and liberty of 
thought and action are the cornerstones 
of our country and her institutions. 
Therefore people resent what they term 
prying into their business, even in the 
matter of sanitation. They must be taught 
that it is not only for their neighbors^ 
good, but their own, that they are com- 
pelled to abate nuisances. Liberty of ac- 
tion does not include danger to one's fel- 

Medical men must not fold their hands 
and keep silent. To a large extent they 
are the educators of the people; to them 
the people look for guidance in matters 
of health, and through them must the 
people be made to understand that certain 
diseases are preventable, and that if each 
will see that ''^his own front yard is 
clean,'' he and his neighbor will fare bet- 

Smallpox has been almost rooted out. 
Typhus is almost now unknown ; and so 
may it be with other diseases if we but put 
our shoulder to the wheel as guardians of 
the nation's health. A great duty de- 
volves on the board of health of the com- 
munity. Generally, they are men of hon- 
esty of purpose; but too often the office 
is a convenient resting-place for the weary 
political worker or his crony, and the post 
is filled by men who know nothing of san- 
itation, and who care only for the paltry 
honor and perquisites of the position. 
Such things ought not to be, and the sooner 
the position of member of the board of 
health is taken out of the hand of politics 
and made honorable, the better it will be 
for the communities at large. The sooner 
medical men preach the great gospel of 
cleanliness in daily life and the importance 
of prevention, the better will it be for the 
public health. Cholera has probably been 
prevented from visiting this country, but 
there are other diseases against which we 
must keep up the struggle of prevention. 
Therefore, watch! 


Bacteriological Notes. Vol. Ixix 


The Bacillus of Diphtheria (Klebs- 
Loeffler Bacillus.) 

Although several species of bacteria, 
including micrococci and streptococi^ have 
been attributed with more or less evidence 
as the etiological factors in diphtheria, the 
Klebs-Loeffler bacillus is now generally 
accepted as the cause of the disease. 
This germ was first described by Klebs in 
1883. He found it the diphtheritic mem- 
brane but did not succeed in isolating it. 
In 1884 obtained it in pure cul- 
ture and since that time it has been known 
as the Klebs-Loefifler bacillus and its eti- 
ological value has been demonstrated by a 
large number of investigators. 

Morphologically this bacillus varies very 
considerably. The rods are straight or 
slightly curved with ends rounded. They 
have a diameter of from 0.5 to 0.8 micro- 
milleters and in length vary from 1.5 to 3 
micromillimeters. One end of the bacillus 
is frequently club-shaped and irregular, 
forms which are almost,if not quite, charac- 
teristic of this organism. In an unfavorable 
culture medium the forms are especially 
varied, one or both ends being thickened 
or an expansion in the central portion of 
the bacillus. Occasionally the rods appear 
to be made up of irregular oval or spheri- 
cal segments. No spores have been ob- 
served and the bacteria do not grow in fil- 
aments. It is stained with the ordinary 
aniline dyes. It takes the Graus stain. 
In order to demonstrate the bacilli in 
diphtheritic membranes, Welch and Abbott 
state that ^^ Nothing can surpass in bril- 
liancy and sharp differentiation, sections 
stained doubly by the modified Weigoit's 
fibrin stain and picrocarmine." In cover- 
glass preparations from the membrane the 
diptheria bacilli can be quite readily dis- 
tinguished, especially if the Graus stain 
has been used. 

Biologically, the diphtheria bacillus is 
aerobic and faculative anaerobic. It de- 
velops in various culture media at a tem- 
perature varying from 20°-42°0. The 
most favorable temperature being about 
35°C. On nutrient agar the colonies are 
of a grayish yellow color, their outlines 
are not sharply defined and a rough almost 
reticulated surface. The growth is not 
very rapid. It grows in gelatine but does 
pot liquify it. In bouillon it impai'ts a 

uniform cloudiness to the liquid ; occasion- 
ally, however, the growth is in the form of 
whitish masses along the sides and in the 
bottom of the tube. The growth on pota- 
to has been questioned but Welch and 
Abbot found that it did develop on ordi- 
nary steamed potatoes. This bacillus de- 
velops in milk and, as it grows at alow tem- 
perature, it may be easily communicated 
from one person to another through this 

The bacillus of diphtheria retains it& 
vitality in cultures for several months. It 
has been known to live for nine weeks in 
dried fragments of the dipth critic mem- 
brane. It is destroyed by heat at a tempera- 
ture of 58°C. after an exposure of ten; 

The bacillus of diphtheria is fatal io 
rabbits, guinea-pigs and cats. Eats and 
mice are remarkably immune to inocula- 
tions of this germ. When rabbits or cats- 
are inoculated in the trachea with cul- 
tures, a characteristic diphtheritic infiam- 
mation is produced, which is followed 
with general toxemia and death, from the- 
absorption of soluble toxic products- 
formed at the seat of inoculation. This 
has been and still is believed to be the 
cause of death in the human species suf- 
fering from this disease. This is evi- 
denced by the large number of bacterio- 
logical examinations that have been made 
with negative results from the blood and 
organs of animals and people who have 
perished from this disease. That bacteria 
are only found at the point of inoculation 
has been the accepted belief. This fact 
renders the recent discoveries of Frosch 
and others, of the diphtheritic bacilli in 
the various organs of the body, of consid- 
erable importance in throwing light upon 
the possible range of distribution of these 
bacteria within tl^e body. 

The length of time during which the 
bacilli retain their vitality and their power- 
to develop so abundantly in milk are facts 
worthy of consideration in the isolation of 
cases and the preventive treatment of 
other members of the family. The local- 
ization of the bacteria on the mucosa of 
the mouth and pharynx renders the mar- 
velous results which have been reported 
by local antiseptic treatment quite possi- 

July 8, 1893. 

Bacteriological Notes. 


A Contribution to the Pathology of Ex- 
perimental Diphtheria, with spe= 
ial reference to the appear= 
ance of Secondary Foci in 
the internal organs. 
Abbott {Bulletin of the Johns Hopkins 
Hospital^ IV. 1893, p. 29,) gives an ac- 
count of some very interesting alterations 
produced by the bacilli of diphtheria. 
In addition to the lesions usually found in 
experimental animals as indicated by the 
investigations of Welch and Flexner (ibid 
II. 1891, p. 105,) Dr. Abbott describes 
the special lesions in the omentum "which 
consist in minute yellowish, lens- shaped 
foci, usually between the peritoneal layers 
and usually circumscribed in outline." 
" When visible to the naked eye they are 
rarely larger than the eye of a small cam- 
bric needle, and of about the same shape. 
They are occasionally larger than this, but 
more commonly smaller, being frequently 
so small as to be detected only by micro- 
scopic examination of sections of the 
hardened and embedded omentum. As a 
rule the omentum containing these bodies 
is somewhat congested, and often presents 
a shriveled appearance at its free margin. 
It is in this free margin that the foci are 
most commonly to be found. Upon mi- 
croscopical examination these nodules are 
seen to be sometimes very sharply circum- 
scribed, while again they are slightly less 
regular in outline. At times they may be 
seen lying between the folds of the peri- 
toneum, while again they will be limited to 
the walls of lymphatic spaces. Upon 
closer examination they are seen to consist 
of polynuclear leucocytes and those hav- 
ing the horse-shoe-shaped nucleus closely 
packed together. The majority of the 
leucocytes composing the nodules contained 
bacteria which in tbeir morphological and 
staining peculiarities were identical with 
the bacilli of diphtheria." In one instance 
pure cultures of virulent diphtheria bacilli 
were obtained from an unusually large 
nodule. The histological structure of the 
nodules is simple, consisting of masses of 
leucocytes, many of which are in the 
phagocytic condition. 

Until comparatively recently, the opin- 
ion in regard to the relation of the diph- 
theria bacilli to the organism in which 
they are located has been that they re- 
mained at the point at which they had 
been deposited, bu"!} recently evidence has 
been obtained which will cause a modifica- 

tion of the original theory of localization. 
Erosch {Zeit f Hygiene, 1893, p. 49-52.) 
has reported the discovery in the internal 
organs of diphtheritic bacilli in 10 out of 
15 fatal cases of the disease. The way in 
which the bacilli gain entrance to the in- 
ternal organs is not known, but Abbot 
believes that the evidence now at hand in- 
dicates that their invasion is accomplished 
by means of the phagocytic cells. 

Acute Ulcerative Endocarditis Due to 
the Bacillus of Diphtheria. 

Howard {Bulletin Johns Hopkins Hos- 
pital, iv. 1893, p. 30) records a case of 
acute endocarditis due to the diphteria 
bacillus. The affection was in a man aged 
44. It began with a chill, high fever, 
pain in the head, abdomen and limbs. 
The disease ran a course lasting seventeen 
days. The endocardium was found to be 
rough, ulcerated and hemorrhagic. The 
spleen, liver and kidneys were diseased. 
Cover-glass preparations, made from a 
thrombus- mass on the mitral valve and 
from the spleen and kidneys, all showed 
the presence of a bacillus with all of the 
morphological characters of the bacillus 
of diphtheria. This bacillus was the only 
organism found. Tubes of glycerine agar 
were inoculated from the mitral valve, the 
lungs, the liver, spleen and kidneys, all 
of which developed pure cultures of this 
bacillus. This germ has been studied by 
Prof. Welch and Dr. Abbott, as well as by 
the author, and the only point in which 
it was found to differ from the diphteria 
bacillus was its failure to kill experimental 
animals. The microscopic examination 
of the tissue showed the bacilli to pene- 
trate to the depth of only two to three 
layers of cell in the endocardium. The 
histological study of the organ demon- 
strated the fact that the bacillus concerned 
in the lesions present is to a certain extent 
a pus-producing organism. There was a 
decided hyaline degeneration noted in the 
muscle tissue of the valves of the heart. 
As the author states, "the striking points 
in this case are a malignant endocarditis 
with general infection caused by a bacil- 
lus that is morphologically and by culture 
methods indistinguishable from the bacil- 
lus of diphtheria." Here we have not 
only a wide distribution of the bacilli in 
the body, but the primary lesion situated 
in a very unusual place (endocardium). 
Although this bacillus failed to kill guinea 



Vol. Ixix 

pigs, others have found the Klebs-Loeffler 
bacillus unable to destroy these animals. 
According to Prof. Welch, this is the first 

time that the - bacillus of diphtheria has 
ever been found to be the cause of ulcera- 
tive endocarditis. 



and that the mechanism of its production 
is simple enough and readily understood. 
Its pathogeny, however, is more compli- 

Rendu, in treating of this subject {Le 
Bull. Med., May 28, '93) says that simple 
catarrhal jaundice has probably some in- 
testinal complication as its point of origin, 
cated. Very probably, as Chanffard has 
first shown, it is due to an attenuated and 
benign affection, but nothing definite can 
be stated. However, there exist other 
forms of jaundice, truly infectious in na- 
ture, which follow in the course of gen- 
eral diseases and which are very difficult 
to explain. He reports two cases, one oc- 
curring in a woman of 67, who appeared 
to be suffering with a pneumonia of the 
apex, and in whom a jaundice supervened 
without any obstruction of the biliary 
passages, and the other in a man 32 years 
of age, who developed a marked jaundice 
in association with a facial erysipelas with 
cerebral complications, but without ob- 
struction of the bile-ducts. 

Such cases undoubtedly have a certain 
connection with malignant jaundice. 
This question of pleiochronic jaundice, as 
it has been called, is a very complex one, 
as yet unsolved. Anatomically there ex- 
ists a very great difference between these 
patients and those with catarrhal jaun- 
dice, namely, that in the former the bili- 
ary passages are absolutely permeable. 
This is a capital point on which are based 
fundamental clinical differences, viz : the 
colored robes, at times the bilious diar- 
rhoeas, the urine more or less deeply pig- 
mented, bat less than in jaundice by ob- 
struction. A second difference consists 
in the almost complete absence of hemor- 
rhage in the' two cases reported, while 
grave jaundice is accompanied, so to 
speak, invariably with hemorrhage of the 
skin and mucous membranes, particularly 

t Translated for The Medical and Surgical Repor- 
TKit, by W. A. N. Borland, M. D. 

with melena and epistaxis. We cannot 
consider as hemorrhagic manifestations 
the several ecchimotic taches which the 
female patient presented on her wrists, 
nor the insignificant drops of blood 
which constituted an attempt at epistaxis 
in the second patient. 

Eendu insists upon the point that at 
the base these jaundices that are allied 
to the infectious diseases have close affin- 
ities with malignant jaundice. They are 
not per se of the nature of grave jaun- 
dice, but they become such by virtue of 
their concomitant visceral complications, 
notably the renal complications. This 
law is verified in the two cases reported. 
In both the kidneys were functionally 
bad, the urine scanty and albuminous. In 
this form of jaundice he claims that the 
renal lesions are, so to speak, the key to 
the problem. The biliary poisoning adds 
to itself a poisoning of urinary origin ; the 
kidneys become unable to eliminate the 
poisons and become altered, the more in 
proportion as the impregnation of their 
epithelium by the bile is older and more 
profound. The kidney, however, is not 
alone in the causation of the rapid evo- 
lution of the malignant jaundice. The 
lesions of the liver play a certain import- 
ant role. This fact cannot be doubted 
when we find, as in the second patient, 
the lesions of cirrhosis and interstitial 
hepatitis. But the alterations are not al- 
ways evident, and in fact the liver may 
appear almost healthy, aside from the bil- 
iary impregnation. That which is impor- 
tant to bear in mind is that in this variety 
of jaundice the poisoning of the economy 
is always of a complex origin, and that 
the patients do not succumb only to bili- 
ary poisoning. It is well known besides, 
as proven by the experiments of Yulpian, 
that injections of bile are relatively but 
slightly poisonous. This will explain the 
long persistence of certain forms of chronic 

July 8, 1893. 



jaundice whicli only moderately alter the 
general health. 

An interesting point is the frequent as- 
sociation of pneumonia and jaundice. Gri- 
solle, long ago, remarked that pneumonia 
of the apex very frequently accompanied 
the grave forms of jaundice, a statement 
that destroys, by the way, the theory of 
hepatitis by continuity. Gubler, in 1872, 
showed that usually in pneumonia the 
jaundice is not biliary but hemapheic — 
the theory of blood jaundice. He ex- 
plained it by the exaggerated destruction 
of the blood corpuscles, causing the escape 
into the blood of too much unused hemo- 
globin, thus giving rise to a coloration of 
the tissues — a greenish yellow. It is ad- 
mitted that the microbes of the affected 
part secrete a poison which is absorbed in 
a different manner by the tissues and thus 
determines variable irritative lesions. 
Whatever may be the form of poison, it is 
interesting to know how the jaundice is 
produced under its influence. Three hy- 
potheses may be advanced: either the 
blood corpuscles are destroyed in the 
blood and the biliary pigment immediately 
formed; or, the irritated liver secretes 
bile abundantly, with a polycholia and 
biliary infiltration of the tissues ; or, fin- 
ally, the later view, there is an obstruction 
to the intra- hepatic biliary circulation due 
to an obstruction of the inter- and intra- 

lobular biliary canaliculi. The first hy- 
pothesis cannot be sustained, as Stern has 
demonstrated. The second hypothesis, 
that of a primary polycholia, due to tox- 
ins which penetrate into the liver, appears 
to Kendu to be an expression of the truth, 
at least in the greater number of cases. 
It is, moreover, proved clinically and ex- 

The treatment of these morbid states, 
unfortunately, belongs to theory rather 
than to practice. Theoretically, the tox- 
ins should be driven out without debilita- 
ting the patient. Here is the difficulty 
of "Jh-Q problem. Purgatives, and espe- 
cially drastic purgatives, are contraindi- 
cated on account of the great prostration 
they induce. Sudorifics, as pilocarpin, 
are not without danger, on account of the 
bad state of the kidneys. Our resources 
are very limited. Eendu thinks the bet- 
ter plan consists in utilizing the natural 
reactions; hot drinks, tea, coffee, which 
provoke at once diuresis and diaphoresis, 
while stimulating the nervous system; in- 
jections of caffeine, which especially an- 
swers for the last indication, are, without 
doubt, valuable; finally, milk diet and 
careful regime for the alimentation of the 
patient. Best of all is to envelope the 
patient in a vv^et jack to induce diuresis 
and perspiration. This may be continued 
for a full hour without danger. 


The author (Dr. Werner, of Markgroni- 
gen,) reports, in detail, five cases, which 
have come to his notice during a practice 
of 40 years. He has never seen a com- 
plete imperforate anus. 

The first case, which happened in 1867, 
a child aged -20 weeks, had suft'ered from 
birth; defecation being extremely pain- 
ful and covering a long period of time, 
owing to the small opening. 

The author made a small incision with 
a bistoury having a blunt end, and enlarged 
the incision with scissors, introducing a 
catheter at once incited the bowel to 
action; the lower bowel was thereby 
emptied. Three days later the child, 
having had no movement during the in- 

* Translated for The Medical and 
Eeporter by Marie B. Werner, M. D, 


terim, was again suffering considerably ; and 
it became necessary to resort to injections 
and the use of the catheter, which again 
gave relief. 

One month later the mother reported 
that the child was well, excepting that it 
was necessary to use the injection daily. 

In February, 1891, the author states 
that the former patient married and had 
two (2) children, and two years after the 
operation she was able to do without the 
injection, and that now she is enjoying 
perfect health. 

Case II. Seen in 1879, age 5 months; 
always seemed to have pain on defecation, 
which had always been thin. Four days 
before, being seen, she had begun to dis- 
charge small, round balls of fecal matter, 
causing great pain. A female catheter 



Vol. Ixix 

was easily inserted ; after being passed 3^ 
c. m. seemed to come in contact with a 
constriction. A further examination 
with the little finger proved the presence 
of an unmistakable stricture. 

The author performed a successful oper- 
ation, which he gives in length; the child 
recovered promptly, was found enjoying 
good health in 1891. 

Case III. Seen first January, 1891, 
aged 11 months; has been suffering since 
birth from difficult defecation. Opera- 
tion same as case second; prompt re- 

Case IV. Seen first August, 1878, 
aged 9 weeks, and had had two previous 
operations; previous diagnosis, complete 
closure of the rectum, which the author 
seems to doubt. An operation seemed to 

be successful, as in others. The commu- 
nication received 13 years later said, how- 
ever, that the boy is well developed, mentally 
sound, but that up to his seventh year had 
had no control over the sphincter ani; and 
even now cannot retain any liquid move- 
ment. An investigation of the parts 
shows a patulous opening, size of a cherry 
stone, large enough to admit an ordinary 
lead pencil ; in passing the finger into this 
opening, one reaches an obstruction, in 
all probability a healthy internal sphincter. 
The child suffers no pain and never passes 
blood or mucus. 

Case V. Seen in January, 1889, the 
child 2-|- months old, which was so sick 
and emaciated that an operation was out 
of the question, died several days after 
being seen. — Memorahilien^ May, 1893. 


. OLD.* 

Gurlt has shown in a statistical table,com- 
prising fourteen hundred cases (prepared 
by B. Gerber, Gyoyazat, No. 14, '93), that 
the above-mentioned fracture occurred but 
in five children who had not yet reached 
their first year. Of these five, there were 
three cases of fracture of the femur, one 
of the scapula, and one of the clavicle; 
none were recorded of the upper extremi- 

Dr. Gerber's case is for that reason, a 
rare as well as an interesting one. On the 
10th of December, '92, he was called to 
see a child, the complaint being made that 
it could not lift the left arm. A careful 
examination revealed a normally developed 
baby whose left arm, at about its upper 
third, was crooked, crepitation being easily 
demonstrated, showing the bone to be 
completely fractured. Reposition of the 
ends was produced by decided conuler exten- 
sion. The entire arm is then encircled by a 
broad bandage, over which a splint made 
of heavy paper was properly adjusted, 
allowing the position of the arm to be at 
right angles, and then bandaged to the 
body after careful protection with cotton. 
The bandage was removed every seven 
days. After the removal of the second 
bandage there was sufficient callus thrown 
out, making the union at that early date 
secure. With the exception of the first 

•••Translated for The Medical anb Surgical Eepor- 
TEK by Marie B. Werner, M. D. 

few days, when a slight oedema of the 
fingers and hand was present, and which 
was removed by a gentle massage, the 
fracture healed thoroughly in three weeks, 
with no untoward symptoms. — Der Kin- 
der Arzt, May, 1893. 



To THE Editor of the Medical and 
Surgical Reporter: — Sir: Permit me 
to testify to the efficacy of the methods of 
staying epistaxis, recommended by Dr. 
Phillips in your issue of the 6th of May,, 
p. 709. The method has been long known 
and practiced in Dublin. We ascribe it& 
introduction to Mr. Josiah Smyly, from 
whose son, Mr. (now Sir Philip), Smyly, 
I learned the method as a student of the- 
Meath Hospital of this city. 

Yours truly, 

George Eoy. 
7 Cavendish Row, E. R. C. S., Rutland 

Square, East, Dublin. 
June 9th, 1893. 

Treatment of Acute Coryza. 

T> Salol 10 

X>5 Acidsalicyl 2.0 

Tannin i .0 

Acid boric 40.0 

M. ft. pulv. 

Sig. Use as snuff every hour. 

— Der Kinder, Arzt., May, ^93. 

July 8, 1893/ 




Win. E. Hnggard, of Davos Platz, 
Switzerland, sends the following: All 
cases of tubercular disease of the lungs 
("consumption") take origin directly or 
indirectly from other cases. This is now 
an established fact. Infection, however, 
is easily provided against if certain simple 
precautions are taken. 

The chief modes of infection are: — 

1. By inhaling dried and pulverized 

This is apt to occur when an ordinary 
pocket-handkerchief is used by a tubercu- 
lar person for expectoration. When such a 
handkerchief is opened, the dried expecto- 
ration is likely to be pulverized and dif- 
fused through the air. Thus it may be 
inhaled by others, as well as by the 
patient himself, who is likely to suffer 
from drawing disease-germs into portions 
of lung previously unaffected. 

Another source of pulverized expector- 
ation is the habit of spitting on the 
ground. The expectoration becomes 
mixed with dust, and then is easily car- 
ried into the air. This habit, therefore, 
is not merely offensive, but dangerous. 

2. By using spoons, cups and other 
articles of the kind ivhich have not leen 
'properly washed after having leen used ly 
tuhercular persons. 

3. By kissing. 

This source of infection is especially to 
be guarded against in the case of chil- 

Self-infection may occur, in addition to 
the ways mentioned, ly swalloiviug the ex- 
pectoration. This habit is likely to lead 
sooner or later to infection of the intes- 
tines with tubercular disease. 

Knowing the channels of infection, we 
can easily take effective precautions. 

The sputum must he destroyed, and must 
not le allowed to lecome dry. 

A spitting-cup or flask containing just 
enough disinfectant solution to cover' the 
bottom of the vessel should alvrays be 
used for the expectoration. Out-of-doors 
a pocket spitting-flask, such as Dett- 
weiler's, should be employed. 

Pieces of linen or calico about ten 
inches square may also be carried. These 

should be used only in case of absolute 
necessity, and should be burnt as soon as 
possible afterward. No piece should be 
used more than once. 

Bedrooms that have been occupied by 
tubercular patients should he thorougldy 
disinfected before they are occupied by 
other persons, and a declaration or assur- 
ance on the point should always be de- 

If the previous occupant of the room 
never allowed the furniture, hangings, or 
carpets of the room to be contaminated 
with the sputum, there would be little 
need for this precaution. But as people, 
ordinarily of cleanly personal habits, 
sometimes show a surprising amount of 
ignorance or carelessness in this respect, 
the following points should be insisted 
on : — 

1. Carpets, curtains, and bed-coverings 
should have been exposed to superheated 
steam under high pressure. 

2. The floor and walls of the room 
should have been properly disinfected. 
(Eubbing with new bread followed bj? the 
application of corrosive sublimate solution 
is probably the most effective practical 

There is no danger of infection from 
the Ireath of a tulercular patient. The 
sole danger of social intercourse arises 
from neglect of the precautions described. 

Fresh air is of the highest importance 
for tubercular persons. Hot and stuffy 
rooms have an evil influence over the dis- 
ease. Except in special circumstances, 
the bedroom window should be kept open 
by night as well as by day. — TJniv. Med. 

A Magnificekt Miceoscope, costing 
eight thousand seven hundred and fifty 
dollars, has been manufactured at Munich 
for the Chicago exhibition. It possesses a 
magnifying power of fourteen thousand 
diameters, and can be increased to sixteen 
thousand with oil immerson. Electricity 
furnishes and regulates the source of light, 
which, placed in the focus of a parabolic 
aluminium reflector, reaches an intensity 
of eleven thousand candle power. 


Current Literature. 

Vol. Ixix 


Dr. Charles P. Noble contributes two 
papers ; the first. 

Certain Cases of Neglected Pus^tubes, 

He reports three cases of pyosalpinx which 
were allowed to run their course. The first 
case died, after years of pain and invalidism, 
with a huge collection of pus in the abdomen. 
The second patient had arrived near the 
period of the menopause without conceiving. 
The cervix was dilated with the idea of cur- 
ing the dysmenorrhoea with which she 
suffered. The result of the operation was a 
violent attack of peritonitis and pus formation. 
The abscess finally burst into the bowel and 
<?ontinues to discharge at intervals. Dr., Noble 
advised the removal of the pus sac. In the 
remaining cases, the trouble followed the 
introduction of sponge tents into the uterus 
lor the cure of a catarrh. The patient had an 
attack of so-called typhoid fever following 
the treatment, and the abscess finally emptied 
itself through the vagina. The report is pre- 
sented to refute the teaching of those who 
-deny the very serious and even fatal character 
of pyosalpinx when not subjected to early 
removal by coeliotomy. 

The second paper by Dr. Noble is entitled 

Certain Aspects of Puerperal Septicfie= 
mia, witli the ;report of a case of Acute 
Puerperal Cellulitis. 

The author protests against the false position, 
taken by some, of denying the occurrence of 
inflammation of the pevic cellular tissue, 
although he has not met with pelvic cellulitis 
except in the puerperal state, and as an acute 
inflammation ending in resolution or abscess. 
Its occurence is rare, however, as compared 
with intra-peritoneal inflammation, due to sal- 
pingitis or to ovaritis. In the treatment of 
puerperal sepsis after it has extended to the 
tubes or to the broad ligaments, the use of 
the curette or intra-uterine douche is not 
advisable. We must trust to nature, assisted 
by our remedies, to bring about resolution, or 
in case of pus formations must resort to op- 
eration. Much depends on whether the 
secondary inflammation is in the tubes and 
peritoneum, or in the broad ligament. If in 
the broad the ligament the pus can be 
evacuated through the vagina or over the 
groin. If in the tubes and peritoneum, an 
early section is imperative. 
Dr. Edward P. Davis contributes a paper on 

The Treatment of Large Ovarian Cysts, 
with the report of a case ; Extirpation 
of the Coccyx for Congenital Cyst. 

In the case of ovarian cyst reported, the 
patient died of sudden syncope six hours 
after operation. The total weight of the 
solid and liquid portions of the tumor reached 
the great total of 160 pounds. The author 
raises the question whether it is possible to 
remove so large a mass from the abdominal 
cavity without producing such a change in 
-circulation as to cause fatal syncope. Two 

methods of operating can be practiced ; the 
first is to stitch the cyst to the abdominal 
walls and use drainage, allowing the cyst to 
empty itself gradually ; the second method 
is the removal of the entire cyst as practiced. 

The second case reported, is an example of 
abscess over the coccyx without appreciable 
cause, and accompanied by pain at the sacro 
coccygeal joint, completely relieved, first by 
evacuation of the abscess and then by ex- 
tirpation of the coccyx. 

Dr. R. R. Kime discusses 

Ectopic Pregnancy- 
and Treatment. 

-Pathology, Symptoms 

In regard to the treatment, he says: In 
primary or secondary intra-peritoneal rupture 
of the ectopic sac, operate by coeliotomy at 
once. Before primary rupture, extirpate cyst 
tube and ovary. Foeticide for this condition 
by means of electricity and morphia injec- 
tions, are but temporary expedients, suitable 
for cases of doubtful diagnosis, or when a 
competent operator cannot be had. With 
extra-peritoneal primary rupture into the 
broad ligament in the early weeks of gesta- 
tion, producing hematocele, if absorption 
fail, then perform coeliotomy or vaginal 
draining. If the child survives primary 
rupture into the broad ligament, let the foetus 
live, keeping the patient under strict observ- 
ance, ready to operate at any time when the 
life of the patient demands it or when the 
foetus has reached a viable age. Surgical in- 
terference should be the rule in all cases of 
ectopic pregnancy reaching full term, even 
after spurious labor and the death of the foe- 
tus. After the operation, never give opiates; 
have the bowels well moved early by salines 
and enemata; no food, only sips of warm 
water until the bowels are moved and vomit- 
ing ceases. Early catharsis relieves pain, 
nausea and prevents intestinal obstructions. 
He has never regretted giving cathartics early 
after operation, but has seen the evil effects 
of delay. 

Dr. W. Reynolds Wilson contributes a 
paper on " Uterine Thrombosis Following 
Post-partum Hemorhage and Its Relation to 
Puerperal Infection." 

In this issue also appears a reprint of Dr. 
Oliver Wendell Holmes' classic essay on 
"The Contagiousness of Puerperal Fever," 
this year being the semi-centennial of its 


contains a paper by Dr. F. C . Hotz on 

The Importance of Early flastoid Opera= 
tions in Acute Suppurative Otitis. 

If the mastoid inflammation is not relieved 
after a week's trial of antiphlogistic measures 
(such as blood letting or leeches behind the 
ear, the douclfing of the tympanic cavity 
with warm boric acid solutions, etc.), the au- 
thor thinks that it may be taken for granted 
that by this time the mastoid antrum is filled 

Julv 8, 1893. 



with pus, and that this pus must be removed 
if the patient is to get well speedily. Many 
surgeons perform the mastoid operation on 
the installment plan, so to speak. Where 
leeches, warm fomentations and other treat- 
ments have failed to give relief, they make a 
Wilde's incision, and wait a day or two for 
results; and when they are satisfied that this 
incision also failed to stay the inflammation, 
then they proceed to open the cells. 

In operating the author prefers the chisel 
to the drill. 

Dr. Charles Warrington Earle contributes 
a paper on 

The Present Status of the Etiology of 
Whooping Qough and Its Treatment 
with Bromoform 

The author is satisfied of the bacterial ori- 
gin of the disease, and states that with brom- 
oform the paroxysms are diminished very 
greatly within three days after the com- 
mencement of treatment. It should be 
given in doses of from one-half drop to a 
child one year of age to two or three drops 
to children of five or six, suspended to some 
naucilaginous vehicle. Syrup or water should 
not be added to the prescription, but glycer- 
ine may be used in any quantity without 
precipitation. Its action is somewhat simi- 
lar to that of belladonna. The author be- 
lieves it controls very largely the nervous 
element in this disease. It has not any 
germicide properties. It is useful in the sec- 
ond stage, diminishing the number of parox- 
ysms and in this way bringing the disease 
under control, which, to say the least, ex- 
cites our solicitation and makes us fearful of 
complications where the paroxysms are from 
twenty to thirty each day. Previous to the 
time that his attention was called to bromo- 
form, the author had relied almost entirely 
upon fumigations, using tincture of iodine 
and carbolic acid. With the bromoform to 
comibat the neurotic tendency and the fumi- 
gations of carbolic acid and tincture of iodine 
to destroy the micro-organisms, we have a 
treatment which promises more than any 
other combination of remedies. It is quite 

probable that the action of bromoform and 
belladona may be somewhat similar, but as 
between the two remedies the bromoform has 
given the better results. 

Dr. C. S. C. Plummer contributes a paper 

Punctured Wounds of the Feet, 

being a report of two hundred and three 
cases treated at the Medical Bureau, World's- 
Columbian Exposition, during the "Con- 
struction Period," June 1st, 1891, to May 1st, 

Although treatment varied much in difler- 
ent cases, the routine treatment finally 
agreed upon as being applicable to most cases 
and followed by the best results, was as fol- 
lows : 

1. Thorough cleansing of the foot with 
solution of bichloride of mercury 1-1,000. 

2. Trimming the edges of the wound. 

3. Swabbing out the wound with a probe 
lightly covered with cotton and dipped in 95 
per cent, solution of carbolic acid. 

4. Drainage. 

5. Antiseptic dressing. 

6. Rest. 

Other papers in this month's issue are : 
"The Treatment of Typhoid Intestinal 
Hemorrhages" by Dr. A. A. Knapp, in which 
the author advocates the administration of a 
hyperdermic injection of a quarter grain of 
sulphate of morphia, followed by powdered 
opium in one grain doses every hour while 
awake, unless the respirations fall below 
twelve per minute. The paper includes a re- 
port of cases in which the treatnaent was 
used. Dr. A. E. Hoadley presents a paper on 
"The Importance of Early Mechanical 
Treatment of Hip Joint Disease." The issue 
concludes with a letter from Dr. Keeley in 
which he denies the truth of the statements 
of Dr. Chauncey F. Chapman in his paper 
on "The Bichloride of Gold Treatment of 
Dipsomania" (a notice of which was pub- 
lished in The Medical and Surgical Re- 
porter for March 25th, 1893), and the reply 
of Dr. Chapman, in which he affirms that 
his statements are, in the main, true. 



Heat and Chloroform. 

Decomposition of chloroform by the pres- 
ence of light and heat from an open fire, not 
infreqently occurs and is disagreeable to oper- 
ator, assistants, attendants and patient. Lit- 
tle has been known about the matter until 
the Medical Press and Circular in a recent 
issue called attention to the danger. In 
December last, in this city, during an opera- 
tion for hemorrhoids, chloroform being the 
ansesthetic employed, the operator, anaesthe- 
tizer and attendant began to cough violently; 
this was accompanied with irritation and 
watering of the eyes and dry and irritated 

throat, and a strong and pungent odor of 
free chlorine was noticed. The cough and 
discomfort in eyes and throat continued for a 
considerable time after leaving the operating 
room. It was supposed that the chloform 
was impure, and the bottle with what re- 
mained of its contents was sent to the manu- 
facturer, Dr. Squibb, of Brooklyn, who 
reported, after analysis, that it was entirely 
pure. It was then remembered, that, as it 
was a cold day, an oil heating stove had been 
burning during the operation. This fact Dr. 
Squibb considered as the cause of the decom- 
position of the chloroform with evolution of 
free chlorine. The patient in this case suf- 
fered no discomfort whatever.— J/ed^'ca/ Be- 



Vol. Ixix 

Creolin a Mixture of Crude Carbolic Acid 
and Resin Soap. 

From a trade circular issued by Dr. F. 
Raschig, a competent chemiist and manufac- 
turer, we learn that, 

" Creolin is nothing more than a mixture 
of about 2 parts crude 20 per cent, carbolic 
acid and 1 part resin soap, and consequently 
contains about 10 to 15 per cent, of crude car- 
bolic acid — to which solely it owes its disin- 
fectant power." 

This positive and trustworthy statement is 
made to counter the specious claim by the 
creolin manufacturers that their product is 
"made from coal-tar creasote free from all 
carbolic acid." Dr. Baschig lends emphasis 
to the exposure by pointing out that "coal- 
tar creasote and 20 per cent, crude carbolic 
acid are identical " — thus " hoisting by their 
own petards" his opponents in the argu- 

Creolin has done good service, but is now 
excelled by lysol.— iVb^es on New Remedies. 

Prentiss (D. Webster) on the Effect of 

Pilocarpine in Changing the Color 

of the Hair. 

Having used pilocarpine with great success 
in a case of uraemia. Dr. Prentiss was much 
interested to note its effect on the patient's 
hair. The drug was administered by the hy- 
podermic method in doses of one centi- 
gramme, and the total amount injected (in 
two or three days) was forty centigrammes. 
The hair, which previous to this time had 
been light brown, began rapidly to change its 
color to dark brown, and later became black. 
It also became coarser and thicker. These 
changes occurred not only in the hair of the 
head, but also in that of other parts of the 
body. The author states that two cases of a 
similar effect — though less marked — have 
been recorded, and speaks of the occasionally 
marked effect of pilocarpine in promoting 
the growth of haii.— Med. Bee, April 15, 


The Treatment of Malaria by Means of 
Potassiun or Sodium Nitrate. 

Dr. Peter Euro in " Deutshe Med. Zeitung," 
having experimented with the above salts in 
the treatment of malaria, reports the follow- 
ing : 

1. The nitrate of potassium and the nitrate 
of sodium are specific remedies in typical 
malarial intermittent, whether it assumes 
the quotidian, tertian or quartan form. 

2. Both salts manifest an exact action but 
the sodium salt has the advantage of being free 
from the slightly toxic effect of potassium, 

3. The usual single dose for adults is from 
15 to 24 grains, which may be given in either 
the febrile or afebrile stage. 

4. A decided advantage of these salts is that 
they exert no ill effect upon the digestive 
organs or nervous system, nor do they pro- 
duce any untoward results. 

Tincture of Iron for Burns. 

Dr. E. F. Starr, in the Atlanta M. and S. 
Journal, recommends the application of the 
tincture of chloride of iron, by means of a 
feather or soft brush, as a prompt and efficient 
remedy for recent burns. The application 
should be made as early as possible, and 
should be done thoroughly, moistening it 
everywhere. Where the cuticle is not des- 
troyed or removed, it should be used full 
strength ; if the cuticle is gone, dilute with 
water one-half or two- thirds. 

If used early in scalds and superficial burns 
it not only allays the pain but prevents 

The Iodine Treatment of Goitre. 

Dr. E. Nazaries, Bulletin de la Societe de 
pharmacie de Bordeaux, Feb., 1893 ; Ameri- 
can Journal of Pharmacy, May 1893), re- 
marks that, while iodine has long been used 
in the treatment of goitre, he has met with 
unqualified success by a particular method 
of its use. He dissolves from 75 to 90 grains 
potassium iodine, and from 20 to 30 drops of 
tincture of iodine in about 5 ounces of distilled 
water. A spoonful (whether teaspoonful or 
tablespoonful, not stated) of this solution is 
diluted with a pint of water, and this amount 
taken daily, during and after meals. The 
author insists onithe continued internal use of 
the drug. — N. Y. Med. Jour. 

Diagnosis of Apoplexy. 

Mills [Polyclinic) based the diagnosis of 
apoplexy on the following points ; 

1. The sudden fall with unconsciousness at 
once, no injury perceptible, face white. 

2. Respirations stertorous, noisy, puffing 
cheeks, tendency to Cheyne-Stokes, inter- 
rupted, improved by turning on side. 

3. Right face droops more, and right cheek 
flaps more than the left. Right pupil w idely 
dilated ; left contracted. Retinal veins dis- 
tended. No rotation of head and eyes to one 

4. Pulse full and slow ; temperature sub- 

5. Convulsive movements noted at first 
have ceased ; both arms and legs drop lifeless 
equally. Left side was paralized first. Sen- 
sation almost completely abolished. 


The Surgical Treatment of Cholera. 

Five cases have up to the present time been 
published in which cholera was treated surgi- 
cally. M. Lambotte operated upon two 
patients last autumn. The abdomen was 
opened in the middle line, and the bowel 
sown to the wound, incised and flushed out 
with a solution of corrosive sublinate (1 in 
3000) by means of an India rubber tube one 
metre long. Both patients died. A Russian 
physician, M. Meerovitch, of Ekaterinodar, 
operated upon three patients last August 

July 8, 1893. 



Only a small puncture was made into the 
bowel, which was not stitched to the wound. 
From 2000 to 3000 grammes of a solution of 
tannic acid were injected in two of the cases 
and 4000 grammes of a solution of thymol in 
the third. In all three cases there was a 
fleeting improvement in the symptoms, but 
all the patients died.— ^os?;. 31. & S. Jour. 

Tropical Suppurative Hepatitis. 

Surgeon Patrick Hehir, of the British In- 
dian Service, formulates, in the Indian Medi- 
cai Gazette^ the following pathalogical classi- 
fication of cases of hepatic abscess : 

(1) By far the most common are cases oc- 
curring consecutive to dysentaiy, and arising 
from a secondary infective process affecting 
the liver through the portal circulation. 
These cases arise from : 

{a) The action of septic organisms, such as 
the streptococci, staphylococci, micrococci; or 

(6) The irritation of the products of such 
septic organisms — ptomaines, conveyed to the 
liver from the ulcerated bowels and acting 
primarily on the liver, which plays the part 
of a filter upon the blood conveyed to it by 
the portal vein, or to the irritation of the 
amoeba coli or cercomonas intestinalis, or 
both combined. Cases due to malarial pois- 
oning, the blocking up of the radicles of the 
portal vein by the plasmodia of Laveran, 
these organisms acting as irritants and light- 
ing up the suppurative process. 

(2) Acute sthenic parenchymatous inflam- 
mation resulting from climatic causes, over- 
crowding, alcoholic excesses, excessive heat 
or chill, acting upon a liver already in a par- 
tial state of disorganization. 

(3) Idiopathic cases in which no assignable 
cause can be traced. 

Intestinal Anastomosis. 

Murphy describes an " anastomosis but- 

It consists of two small circular bowls 
made of bone. In one bowl is fitted a small 
cj^linder with a female screw-thread on its 
entire inner surface. In the other bowl is 
fitted a smaller cyUnder, of a size to slip 
easily into the female cylinder. On the inner 
surface of the lower end of the male cylinder 
two small brass springs are fixed, which 
serve to hold the bowls together when the 
male cylinder is pressed into the female 
cylinder. In the side of each bowl are four 
openings which serve for drainage. The 
whole button has the form of two hem- 
ispherical bodies held together by invaginating 
cjiinders. These hemispheres of the button 
are inserted in slits or ends of the viscera to be 
operated upon. A running thread is placed 
around the slits in the viscus, so that when 
it is tied it will draw the cut edges within the 
clasp of the bowl . A similar running thread is 
applied to the slit in the viscus into which the 
other half of the button is inserted, and the 
bowls are then pressed together. The pres- 
sure-atrophy at the edge of the bowl is pro- 
duced by a brass ring supported by the spring. 
The I opening left after the "^button has 
liberated itself is the size of the button. 

For this device the inventor claims the follow- 
ing advantages : (1) It retains its position 
automatically ; (2) it is independent of sutures; 
(3)it produces a pressure-atrophy and adhesion 
of surfaces at the line of atrophy ; (4) it en- 
sures a perfect apposition of surfaces without 
the danger of the displacement ; (5) it is 
applicable to the lateral as well as to the end- 
to-end approximation ; (6) it produces a linear 
cicatrix, and thus ensures a minimum of con- 
traction ; and (7) it it extremely simple in it8 

Three cases of cholecysto-enterstomy with 
this device are reported with apparent good 
results. In one case the time occupied by 
the operation was eleven minutes. Other ex- 
perimental operations on animals are reported 
as having been done successfully. These in- 
clude cholecystic-enterostomy, gastro-intes- 
tinal anastomosis and entero-intestinal ana- 
stomosis. — Bost. Med. and Surg. Jour. 

Bloodless Amputation at the Hip joint. 

Dr. Senn has described a new method, de- 
vised by him, for the bloodless amputation of 
the hip-joint {Chicago Clinical Beview). The 
following conclusions are presented by the 
author, as embodying the advantages of this 
operation : 1. Preliminary dislocation of the 
head of the femur and clearing the shaft of 
this bone of all soft tissues down to the 
proposed line of amputation through an 
external straight incision requires less time, 
is attended by less hemorrhage and shock 
than when this part of the operation is done 
after circular amputation, as advised by 
von Esmarch and others. 2. The external 
straight incision is the same as the von 
Langenbeck incision for resection of the 
hip-joint, differing only in length. 3. After 
dislocation of the femur the soft tissues are 
tunnelled with a haemostatic forceps whichiis 
entered through the external wound on a level 
with the trochanter minor to a point on the 
inner aspect of the thigh behind the adductor 
muscles and about tw^o inches below the 
ramus of the ischium, where a counter-open- 
ing two inches in length is made. 4. Blood- 
less condition of the limb should be secured 
by elastic compression or vertical position 
prior to tying the elastic constrictors. 5. An 
elastic tube three-quarters of an inch in di- 
ameter and about four feet in length is grasped 
with the force in the center and drawn 
through the tunnel made by the forceps. 6. 
After dividing the elastic tube in the centre 
the base of the thigh is constricted by draw- 
ing firmly and tying the anterior constrictor 
in front of the anterior section, while 
the posterior constrictor after being drawn 
tight behind the posterior section the 
two ends are crossed and then made to en- 
circle the whole thigh, when the ends are 
again drawn firm and tied or otherwise se- 
cured above the anterior constrictor. 7. A 
long and short oval cutaneous flap should 
invariably be made in all amputations at the 
hip-joint. 8. In perference a long anterior 
and a short posterior flap should be selected. 
9. The transverse section through the 
muscles should be some what conical in shape, 



Vol. Ixix 

the apex of the cone corresponding to the 
tunnel made by enculeation of the upper 
portion of the shaft of the femur. 10. Re- 
section of the end of the sciatic nerve and 
ligation of all vessels that can be found should 
be done before the removal of the constrictors. 
The femoral arteries should be secur- 
ed by a double catgut ligature spread half an 
inch apart, the one portion on the proximal 
side including also the accompanying vein. 
The posterior constrictor should be 
removed first, and all hemorrhage arrested by 
ligation and compression before the anterior 
constrictor is removed. 13. The upper part of 
the wound corresponding to the acetabulum 
should be drained with an iodoform gauze 
tampon, and the remaining part of the wound 
by one or more tubular drains. — Med. Record. 


Conception on the Fourth Day of 

Kronig {Centralbl. f. Gynak., No. 19, 1893), 
related an extraordinary and instructive case 
at a meeting of the Leipzig Obstetrical So- 
ciety. A woman, now twenty-two, healthy 
and regular before her pregnancies, bore her 
first child on July 4, 1892. It was weaned on 
the tenth day, and is still living. On July 
8, the fourth day of the puerperium, the pa- 
tient had connection and then ab- 
stained for three months from coitus. 
The period did not return. In No- 
vember, 1892, the motion of the child was 
felt. It was born on March 10. It seemed 
as though it had reached term, yet it had 
come into the world 243 days after the only 
connection which had occurred since the first 
confinement, or twenty-seven days — practi- 
cally a calendar month — before the normal 
average of 270. It was over twenty inches 
long and weighed nearly seven pounds 
twelve ounces. 

The shortness of the pregnancy was very 
remarkable, but the conception on the fourth 
day of the puerperium was still more notable. 
Ovulation, according to current theories, is 
entirely suspended during pregnancy, and 
does not recommence until, or a little before 
the first period, which occurs between the 
sixth and eighth week after delivery in 
women who do not suckle. If ovulation was 
delayed so long in this case, the spermatozoa 
must live long ; Bozzi certainly found them 
living seventeen days after coitus, in the pos- 
terior vaginal fornix: but in Kronig's case 
this delay of conception to the first period 
would have made the pregnancy much too 
short to allow of the birth of a well-formed 

In short, ovulation went on quite indepen- 
dently of menstruation. How the impreg- 
nated follicle could find a fit place of attach- 
ment on the inner surface of the uterus is a 
more mysterious question. Yet the glandu- 
lar structures developed during pregnancies 
are often completely shed by the third or 
fourth day after childbirth, so that there is 
soon enough normal endometrium to lodge a 
fresh ovum. It is evident that spermatozoa 
can live in the lochia. — British Med. Journal. 

A Valuable World's Fair Book. 

The Passenger Department of the Baltimore 
and Ohio Railroad Company has prepared for 
general distribution a handsome pamphlet de- 
scriptive of the scenic and other attractive 
features of that road from New York to 
Chicago. This book should prove invaluable 
to those visiting the World's Fair. In its 
artistic cover, illustrations and reading matter, 
it is fully up to the high standard which has 
been fixed by the B. & O. for publications of 
this character. The scenery en route, which 
has gained for the B. & O. the richly deserved 
sobriquet of "Picturesque," the public build- 
ings at Washington, old Harper's Ferry,Luray 
Cavern, and other attractive points are 
faithfully portrayed. The value of the pub- 
lication is increased by descriptions and 
illustrations of the principal buildings at the 
World's Fair. This book can be procured free 
of charge lupon personal application to 
ticket agents, B. & O. R. R. Co.^r you can 
have it mailed to you by sending name and 
address with five cents in stamps to Chas. O. 
Scull, General Passenger Agent, Baltimore, 
Md. World's Fair tourists should bear in 
mind that the B. & O. is selling tickets at 
very low rates good going via Washington 
and returning via Niagara Falls. 

Deer Park and Oakland. 

To those contemplating a trip to the moun- 
tains in search of health and pleasure, Deer 
Park, on the crest of the Allegheny Moun- 
tains, 3,000 feet above the sea level, oflers such 
varied attractions as a delightful atmosphere 
during both day and night, pure water, 
smooth, winding roads through the moun- 
tains and valleys, and the most picturesque 
scenery in the Allegheny range. The hotel 
is equipped with adjuncts conducive to the 
entertainment, pleasure and comfort of its 

The surrounding grounds, as well as the 
hotel, are flighted with electricity. Six miles 
distant on the same mountain summit is Oak- 
land, the twin resort of Deer Park, and 
equally as well equipped for the ehtertainment 
and accommodation of its guests. Both 
hotels are upon the main line of the Baltimore 
and Ohio Railroad, have the advantages of 
its splendid Vestibuled Limited Express 
trains between the East and West and are 
most desirable resting places for World's Fair 
tourists. Season Excursion tickets, good for 
return passage until October 31st, will be 
placed on sale at greatly reduction rates at 
all principal tickets officers thoroughout the 
country. One way tickets reading from St. 
Louis Louisville, Cincinnati, Columbus, 
Chicago, and any point on B. & O. system to 
Washington Baltimore, Philadelphia, or New 
York, or vice versa, are good to stop off* at 
either Deer Park or Oakland, and the time 
limit will be extended by agents at either 
resort upon application. 

The season at these popular resorts com- 
mences June loth. 

For full information as to hotel rates, rooms, 
etc., address George D. DeShields, Manager, 
Deer Park, or Oakland, Garrett County, 

Vol. LXIX, No. 3. 
Whole No. 1898. 

JULY 15, 1893 

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10 Cents a Copy 


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George H. Rhoe. M. D., Catousville, Md. 
Further Observations of the Relation of Pelvic Dis- 
ease and Psychical Disturbances in Women. . S4 


Charles G. Stockton, 31. D. 
Valvular Lesions of Heart, Pulmonary CEdema, 
Oligochromaemia, Simple Anaemia. ... 87 


R. W. Retn-olds Wilsox, Philadelphia. 
Uterine Thrombosis Following Post-Partum Hemor- 
rhage, and its relation to Puerperal Infection. . 90 

Edward P. Davis, 31. D., Philadelphia. 
The Treatment of Large Ovarian Cysts, with the 
Report of a Case; Extirpation of the Coccyx for 
Congenital Cyst 94 

W. H. Link, Petersburg. Ind. 
Clinical Observations in Philadelphia. ... 97 

RuFUS B. Hall, 31. D., Cincinnati, Ohio. 
Abdominal Hysterectomy without a Pedicle, with 
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Medical and Surgical 

No. 1898. 


Vol. LXIX— No. 3 



T. J. HAPPEL,t A.M., M. D. 

I venture to call attention to this mal- 
ady not so mucli with a view of throwing 
new lights upon an old subject as for the 
purpose of eliciting a discussion and a 
comparison of views entertained in regard 
to the disease as it manifests itself in Ten- 

In different parts of the State during 
the year 1892 the existence of diphtheria 
was reported. The county of Gibson did 
not escape. But one case occurred in my 
own practice, but I was called in consulta- 
tion to see cases treated by three other 
practitioners near Trenton ; the cases being 
distant respectively five, six, and ten miles 
from Trenton. I submit a brief history 
of these cases and then draw my conclu- 

Sept. 2, 1892, I was called in consulta- 
tion to see the three children of Mr. V. 
The family lived on an elevated point, 
within 200 yards of an old saw-mill which 
had been abandoned for eight or ten years. 
The sawdust that had accumulated at that 
point lay rotting year after year, affording 
a nice playing place for children, and was 
no doubt so utilized by them. Otherwise 
the place presented as good sanitary sur- 
roundings as are usually found about 
country farmhouses. I found the chil- 
dren aged 11, 6 and 4 years. The oldest 
attended a neighborhood school, and four 

days since, though a little unwell, was at 
her place as usual, but came home that 
evening sick, having high fever. 

During the night Dr. M. was called, but 
did not see the case until the next day, the 
family supposing the attack an ordinary 
chill. Dr. M. at this visit regarded the 
attack as malarial fever with catarrhal 
symptoms, accom^panied by a slight tonsil- 
litis. The next day he found the second 
child also sick, and the symptoms calling 
attention more to the throat, he found 
tonsillitis with extensive exudation in both 
cases. The next day the exudation as- 
sumed the form of pseudo-membrane and 
extended posteriorly and laterally over the 
fauces, and anteriorly along the soft palate 
in the first case, but not so extensively in 
the second. The temperature and pulse 
had both decreased in the first case, fall- 
ing slightly below normal, and in the 
younger the temperature was normal. I 
was called on the fifth day of the disease 
in the oldest child, being the third day in 
the second. 

An examination of the throat of the 
oldest revealed pseudo- membrane on both 
tonsils, not quite meeting in the median 
line posteriorly, and the one on the left 
side extending anteriorly along the hard 
palate fully two inches, loosening along 
the anterior edges, and appearing to 
be about one and a half lines in thick- 

Read before the Tennessee State Medical Society, neSS. 


•f Ex-President Tennessee State Medical Society; 
President Western Tennessee Medical and Surgical As- 

Case 2 showed patches of false mem- 
brane about the size of a nickel on each 
tonsil, extending downward and toward 


Original Articles. 

Vol. Ixix 

the middle. This child claimed not to be 
sick, wanted to play about, with a pnlse of 
120 and a feeble, anaemic look. Face 
pinched and white. The same could be 
said as to the appearance of the oldest 
child, but she admitted that she was sick, 
and was willing to lie in bed, being easily 
exhausted by any exertion. 

The youngest child was a little hoarse, 
with slight fever, but was able to play 
about. His throat revealed no patches, 
only a redness and slightly enlarged con- 
dition of both tonsils. Under a mopping 
of the throat of the eldest girl (having 
first used a wash of peroxide of hydrogen 
full strength, and then following with a 
solution of papoid), in an effort of cough- 
ing, the whole of the large part of this 
membrane attached anteriorly to the hard 
palate was detached and coughed out,leav- 
ing a raw and, in a few points, bleeding 

In the other child's throat nothing was 
detached under the same treatment, though 
very decided action resulted when the 
peroxide was brought in contact with the 
false membrane. Both children were 
much tired by the application. These 
children had been treated up to that time 
with quinine, and aconite and gelsemium 
when temperature was above normal, and 
the throats had been mopped with listerine 
alternated with a saturated solution of 
chlorate of potash, which latter remedy 
had also been administered internally. 
Neither child had any desire for food, and 
none had been forced on them. 

It was agreed first that all clothes, mops, 
etc., used about the throat, or upon which 
any of the secretions from the throat were 
received, should at once be burned. That 
in the absence of an atomizer, applications 
should be made to the throat by means of 
soft mops made of absorbent cotton. 
Second, that the disease should be treated 
locally with applications of peroxide of 
hydrogen (Marchands) followed at once 
by a solution of papoid. Third, that as 
internal remedies, alcohol in different 
forms should be given as demanded by 
each case. Fowler's solution of arsenic 
was ordered every four hours. Fourth, 
the youngest child was ordered sent to a 
relative, who had no children, with direc- 
tions to mop the throat with a solution of 
persulphate of iron and chlorate of potash, 
and given full doses of quinine three 
times a day. Fifth, all children were 

ordered to be kept away from contact with 
the cases. 

Sept. 4th. The appearance of the throats 
of both the children had improved, except 
that the membrane, much thinner and 
smaller every way, had been reproduced 
over the portion of the palate of the oldest 
child from which it had been removed. 
Temperature subnormal in this case with 
a slow feeble pulse, complete anorexia, 
and decided aphonia ; very weak. The 
second child was better in every way. 

Sept. 6th. Throats of both cases im- 
proved so far as pseudo-membrane was 
concerned. Pulse and temperature in the 
oldest child subnormal. Deglutition diffi- 
cult with a tendency on the part of drink 
and food to return through the nose, 
prostration great, with a loathing of food. 
It was decided to add to her treatment a 
pill of iron, quinine, and nux-vomica, 
with phosphorus, and to press alcholic 
stimulants. Prognosis in this case very 
grave. The second child improved in 
every respect. No delopment of disease 
in the third. 

Two days later, gangrenous symptoms 
supervened in the first case, and two days 
later sloughing began. The child died 
suddenly from heart failure on the fifth 
day after my last visit. The other child 
slowly recoverd. The third child did not 
develop the disease. 

On Sept. 6th, I was called in consulta- 
tion with Dr. M. to see a two year old 
child of Mr. T., who also lived not far 
from an old saw mill. A few days before, 
the little boy was found with fever, a sore 
throat and developing croupy cough. Dr. 
M. reported that when he called he found 
a slight tonsilitis, with pharyngitis, also 
a laryngeal cough. At that visit he found 
no membranes. At his next visit the sym- 
toms were the same but membranes 
could be plainly seen. I was called the 
next day. I found the child playing on 
the floor. There was a stridulous cough 
and a shrill respiration which could be 
heard outside of the room. Temperature 
and pulse almost normal. I discovered 
membranous patches on both tonsils. 
There were no other children in the 

The treatment locally consisted of a 
spray of peroxide of hydrogen followed, 
as in the first case, with a solution of 
papoid. Dr. M. had been using sulphur 
by insufflation. This was continued. 

July 15, 1893. 

Original Articles 


Quinine 2 to 3 grs. every 4 hours, to 
be alternated at the same intervals with 
mercuric bichloride gr. ^-^. Egg-nogg, 
milk punch and toddy were directed to be 
freely used. At the third visit, tr. ferri 
mur. was added to the foregoing treat- 
ment. The spraying was kept up regu- 
larly till every trace of the membranes 
had disappeared. The bichloride was not 
suspended till, in addition to the dis- 
appearance of the membranes, the laryngi- 
tis had subsided. Dr. M. had just prior 
to this one lost two patients in the same 

Nov. 6th, saw, in consultation with Dr. 
K.j Miss B., aged 11 years, presenting a 
well developed case of diphtheria with 
slight laryngeal symtoms. She, too, lived 
not far from an old saw mill. Tempera- 
ture for a few days was high, but had fal- 
len to about normal; pulse frequent, 
feeble, and irregular ; prostration decided. 
Her treatment consisted of the same 
spraying and mopping, alcoholics and nu- 
trition, with scrupulous regard for clean- 
liness, and Tr. Ferri Mur. gtt. 4 every 
four hours with ^ : Hydrarg. Bichlor. 
grs. 1, Liq. Arsenici Chlor. drams 1, 
Acid Muriate, dil. drams 2, Glycerinse, 
■drams 3, Aqu^ q. s. oz. 4, ft. mist. 
Sig. : Teaspoonf ul every four hours ; al- 
ternate with the iron. 

From the adoption of this treatment 
her improvement was steady but slow.- At 
the end of two weeks all traces of the dis- 
ease except extreme debility had disap- 

My own case, occurring in Trenton, was 
milder than any of those reported and re- 
covered on about the same treatment, 
except that the throat was treated with a 
solution of persulphate of iron and chlor- 
ate of potash. 

During the pre valance of this disease, a 
number of cases of diphtheritic croup at- 
tached children under two years of age. 
Tracheotomy was performed in at least 
four (4) of these cases with fatal results in 
all. The cases not operated on as a rule 
died also. 

I have thus briefly reported these cases 
to invite your attention to some thoughts 
upon the disease and more especially upon 
its treatment. 

According to the latest writers upon 
the subject, diphtheria is due to a specific 
germ, the Klebs-Loeffler bacillus. This 
statement is made on the ground that in 

cases of diphtheria the pseudo-membrane 
is found inhabited by vast colonies of this 
bacillus. Yet our same bacteriologists 
admit that membranes are found in many 
cases which cannot be distinguished by 
appearance or anatomical characters from 
that of true diphtheria except by the 
absence of the Klebs-Lseffler bacillus ; ergo, 
no case of diphtheria can be positively 
diagnosticated without the aid of a micro- 
scope. Again, in L' Union Medicale, Nov. 
14th, 1892, Eoux and Versin state that in 
fifty healthy children examined in Paris 
and elsewhere in France, they found in 
the mouths of twenty-six of these child- 
ren '' a, bacillus which, in a morphologi- 
cal point of view, is identical with the 
Klebs-Loeffler bacillus." The difference 
which they could discover was not in its 
individual form nor in the form of its 
colony, but only in the numbers of its 
colonies. This being true, does it not at 
once raise the question, or rather establish 
as a fact, what is stated by them to be a 
belief '^ that this harmless bacillus is none 
other than the Klebs-Loeffler bacillus de- 
prived of its virulence ? " 

A search for this bacillus might reveal 
its presence much more common, and 
might carry the etiology of the disease to 
this point. " This Klebs-Loeffler bacillus 
exists in the secretions of the buccal sur- 
faces of many persons, and when brought 
in contact with a tertium quid, causes 
the secretion by these bacilli of a tox-al- 
bumen which is absorbed, resulting ^r52^, 
in the manifestation of local disease and, 
afterward, a blood-poisoning resulting in 
constitutional symptoms."" I simply sug- 
gest this as the probable etiology of the 
disease. The facts are as stated. These 
bacilli are found in the mouths of healthy 
persons. They are also found in pseudo- 
membranes which are not considered 
diphtheritic simply because when the bacilli 
are secured from that source and culti- 
vated, or innoculated, they neither develop 
large colonies nor produce local trouble; 
and yet the microscope cannot differen- 
tiate these bacilli from those found in the 
most malignant cases of diphtheria. If 
this be a solution of the question, I can 
account for the development of the cases 
appearing in Gibson County during the 
past year upon the supposition that in 
nearly every case the rapid decay of the 
old saw-dust, which was near every 
neighborhood in which any case de- 


Original Articles, 

Vol. Ixix 

veloped, furnished the pabnlnm on which 
the bacilli grew and multiplied. 

In connection with the Klebs-Loeffler 
bacilli, the microscope, according to Eoux 
and Versin, shows also staphylococci and 
streptococci pyogenes in the meshes of 
the membrane. The bacilli either live in, 
or cause the production of the pus, which 
is found intermixed in the pseudo-mem- 
branes. For these we will have use later 
on in the treatment. 

It has been further proved by Klebs- 
Loeffler, Eoux and others that if cultures 
of these bacilli are filtered through a 
porcelain filter no bacilli are found in the 
filtrate, and that this filtrate solution in- 
jected causes no local manifestation of 
diphtheria but develops the constitutional 
disturbances seen so often in the disease. 
If the solution is strong or considerable 
in quantity, death rapidly supervenes, but 
if less in degree, the animal "lives longer 
but suffers from paralysis ;^^ hence, the 
statement already made that these bacilli 
generate a tox- albumin as they grow, 
which gives rise to the constitutional 
symptoms. So much for the etiology of 
the disease. 

Prognosis. The statistics of the mor- 
tality differ widely. The reports from 
many of the best hospitals give the rate 
at from 31 per cent, to 47 per cent._, but 
widely different are the reports in private 
practice. Dr. John M. Boyd, of Knox- 
ville, Tenn., in 1888, at the Tennessee 
State Medical Society, read an article on 
diphtheria and veratrum viride, as the 
basis of treatment, in which he used the 
following language: "In the six years 
since, sixty-seven cases have fallen princi- 
pally to my care, and a number of others, 
in which I have had a consultant relation^ 
and under its (veratrum's) timely use, its 
claims to the merits of extraordinary 
efficiency have never disappointed me."" 
One practitioner in Washington City 
claims in private practice, fifteen succes- 
sive cases without a death. ( Va. Med. 
Monthly, Feb. 1893, page 908.) Osier 
holds that in hospital practice the disease 
is very fatal but that in private practice, 
except in very malignant epidemics, the 
prognosis is very good. 

My own experience with the disease, 
whilst limited, is not favorable. Almost 
without exception the cases of diphtheritic 
croup where the presence of membrane 
was fully proven, were fatal. I admit 

that one or two recovered out of twelve or 
fifteen eases seen and reported, but no 
membrane could be demonstrated except 
in one case. 

In a^discussionof the question of mem- 
braneous croup, which took place in the 
G-ibson County Medical Society this year 
(1893), the members speaking to the 
question and taking the position that 
membraneous croup and diphtheria were 
identical, reported a number of cases 
which had come under observation. One 
member reported seventeen cases of diph- 
theritic croup met with in a series of years, 
all fatal; another, five cases with four 
deaths ; another, five cases in which 
tracheotomy had been performed, all fatal; 
another did not give the number of cases 
but reported all fatal. The mortality was 
at least twenty per cent of those cases 
seen bv, and reported to me in the fall of 
1882. " 

This wide difference of results can be 
accounted for only upon the supposition 
that many cases are diagnosed diphtheria 
which are only cases of tonsilitis, or of 
pharyngistis with an exudate not a false 
membrane. These exudates sometimes so 
closely resemble the diphtheritic mem- 
brane that the eye cannot distinguish 
them, yet the microscope promptly shows 
the difference, while the simple test of 
agitating them in warm water would give 
strong proof for or against the disease ; — 
the exudate generally readily dissolving, 
or at least separating into small frag- 
ments, whilst the diphtheritic membrane 
will not. Of course, the " whipiug off" 
test with soft absorbent cotton will aid 
very materially in making a diagnosis 

Tkeatment. — This should be local and 
constitutional, in accordance with the 
modern ideas of the disease. Eemedies 
for local application have been almost as 
numerous as are pharmaceutical prepara- 
tions. Without attempting to discuss the 
merits or demerits of the large majority 
I would simply call attention to those that 
I have found useful. In the first place I 
put peroxide of hydrogen. The fact that 
we find in these pseudo-membranes strep- 
tococci pyogenes — the pus generating 
cocci — and that pus is held in the meshes 
of this membrane, and the further fact 
that has been proven beyond cavil, that it 
hunts out, combines with and decomposes 
these pus globules proving at the same 
time a germicide of the highest type, 

July 15, 1893. 

Original Articles, 


Hydrogen Peroxide becomes then the ap- 
plication par excellence in these cases. 
This I use if I can, first with a soft mop 
made of absorbent cotton, and then, in 
order that I may not fail to reach mem- 
branes hidden from sight, I follow by a 
spray of the same through the anterior 
nares and mouth. In young children, I 
use the spray alone to avoid so much 
worry. I use the reagent undiluted un- 
less I find it irritating ; then I dilute as 
little as possible. 

After a few moments rest, with another 
mop I saturate the membranes wherever 
visible, with a solution of papoid, (vegeta- 
ble pepsin) nine grains to the drachm. 
This, in my hands has proven a powerful 
solvent of these membranes. These applica- 
tions are repeated in bad cases every two 
hours, in milder ones every four hours. 

I cannot say that I have gotten any ben- 
efit from solutions of iron or chlorate of 
potash locally in these cases, though I 
frequently use the potash solution as a 
gargle with children old enough to use it. 
In some of my cases I caused sulphur to 
to be blown into the throat to satisfy a 
popular prejudice, at the same time hop- 
ing that it might be converted into sul- 
phurous acid and act as a germicide or by 
attrition at least aid in wearing off the 
membrane. Externally I make stimulat- 
ing applications to the throat. 

Recognizing that this disease rapidly 
becomes constitutional I open up the 
alimentary canal with a mercural purge 
and then direct that the secretions of 
bowels, kidneys and skin be carefully 
watched and kept normally active. 

The high temperature of the first 
twenty- four or forty-eight hours demands 
antifebrine or some other of the phenol 
group of antipyretics, repeated as often as 
needed to hold the temperature down to 
or below 100.° Generally there are several 
days when heart sedatives may not be 
needed at all, but as the disease progresses 
it will become necessary to tone and re- 
duce the frequency of the hearths action. 
This can best be done with digitalis and 
aconite combined, in small doses often 
repeated. Later on the aconite must be 
omitted, the digitalis kept up supple- 
mented by alcoholics freely administered. 
Alcohol in some form becomes a most 
valuable adjuvant in the treatment of 

As to constitutional remedies, bichlor- 

ide of mercury stands first and should be 
given in full doses every four hours. For 
a child two years old, I do not hesitate to 
order one forty-eighth of a grain every 
four hours, but I should hesitate with so 
young a child, to go to the extent sug- 
gested by Osier, viz: one-half a grain in 
all, each day. Next in utility is tr. ferri. 
chlor. in doses of four to ten drops every 
four hours, for a child two years old, and 
two grains of quinine at the same time. 

Third in value is placed liq, potasii ar- 
senitis, or chloride of arsenic. Favorite 
prescriptions of mine are 

T> Hydrarg bichlor i grain 

XV Alcohol q.d. ft. sol 

Iviq. arsenici chlor i % drachms 

Acid, muriatici dil 2 drachms 

Potassii chloratis 3 drachms 

Aquae q.s., 4 ounces 

M, et ft sol. 

Sig.— Teaspoonful in water every four hours. 

Alternate with tr. ferri mur. in doses 
already stated every four hours. 

I do not propose to refer to all other 
remedies used, but these have been found 
valuable in my hands. If, in the course 
of the disease, diphtheritic croup develops, 
then an atmosphere charged with the 
vapor of turpentine and eucalyptol is to be 
abundantly supplied to the patient, either 
by surcharging the air of the room by 
means of a vessel of boiling water con- 
taining these medicines (such can easily 
be arranged with a gasoline stove or large 
alcohol lamp) or the vapor may be con- 
ducted close to the child's face by wetting 
cloths in the mixture and hanging around 
the bed. In such cases an emetic will 
often be needed to dislodge the mucus 
from the trachea and bronchi. Ipecac in 
the form of the fluid extract has giyen 
me most satisfaction. I generally use it 
combined with belladonna. Belladonna 
is strongly indicated in these cases when 
the blood is not properly aerated. 

The question of intubation or trache- 
otomy presents itself in most of these 
cases. From the failures in tracheotomy 
cases I would favor intubation. But it is 
not the province of an article of this kind 
to discuss the relative merits of either. 

Whatever treatment is adopted, the re- 
sult depends largely on the nature of the 
case, whether sporadic or epidemic, whether 
simple, mild, or malignant. If the etiol- 
ogy assumed is correct, the treatment sug- 
gested ought to prove curative. It has 
done good in my hands ; hence I present 


Original Articles. 

Vol. Ixix 

Sequelae must be met as they arise, 
although it is better to prevent them by 
closely watching the case and resorting in 
time to proper remedies. For example: 
The timely use of strychnia, hypodermi- 
cally or per orem, may prevent paralysis. 
Shonld it develop, no time has been lost 
and we are prepared to continue our treat- 
ment more regularly. 

I have not entered upon the question of 
prophylaxis, because, in this enlightened 
age, no one can or will deny the absolute 
necessity for the adoption of the most 
thorough and careful preventative meas- 

In conclusion, it must not be forgotten 
that we are dealing with a disease of which 
the virus or germ, or whatever the source 
of infection may be, is most tenacious of 
vitality, and hence, in all cases, everything 
used around a case of diphtheria should 
be thoroughly disinfected by heat dry or 
moist, fumigation with sulphur, washing 
with bichloride solutions, etc. These 
measures should include rooms, beds, bed- 
ding, clothing, etc. Cases have been re- 
ported of diphtheria developing in fami- 
lies which have moved into houses that, 
weeks or months before, had contained a 
case of diphtheria. 



GEORGE H. RHOE, M. D., Catoxsville, Md. 

At the last annual meeting of this as- 
sociation, it was my privilege to report 
eighteen cases of removal of the uterine 
appendages in insane women, with the 
results following the [operation. In sup- 
plementing my previous report with this 
brief paper, I desire to touch upon a feat- 
ture of the question which has arisen in 
the interval ; namely, the medico-legal 
relations of this work. 

Of the eighteen cases reported last year, 
three had been discharged recovered at 
the date of the report. These cases up 
to the time of this writing, remain well 
and continue doing their daily household 
work. One other has been at home for 
seven months, not entirely well, but so 
much improved that she can be cared for 
outside of an insane hospital. 

Another case (of seven years' residence 
in the hospital) has so much improved in 
disposition since the cessation of the 
periodical menstrual irritation that I look 
forward to discharging her from the hos- 
pital also. 

Since last September I have operated on 
two additional cases, one of periodical 
maniacal violence, and the other of mel- 
ancholia with loud complaints of intense 
headache. In both cases the ovaries were 
cystic. The former case has had no out- 
break since the operation, but is still de- 
tained for observation, while the latter has 
been discharged entirely recovered, a re- 

covery dating from convalescence from the 

The simple results of this work are 
therefore as follows : 

Twenty operations (removal of the 
uterine appendages) upon insane women 
with pelvic disease. Eighteen physical 
recoveries from the operation, with 
improvement of the general health. Two 

Four absolute mental recoveries and 
discharge of patients from hospital re- 
straint. (2 thirteen months, 1 ten months, 
1 two months). 

Three with complete physical and par- 
tial mental recovery. (1 at home seven 

Seven show mental improvement, some 
of them of a very decided character, but 
none sufficient to justify discharge from 
the hospital. 

Three remain in about the same mental 
condition as before the operation but are 
much improved physically. 

One was removed from the hospital a 
few weeks after the operation against my 
advice, and then placed in an Asylum, 
where I am informed she has been grow- 
ing worse mentally. 

I may also refer here to a case of melan- 
cholia with suicidal tendencies, in which 
I repaired a badly lacerated cervix. The 
operation was followed by rapid restoration 
of the mental faculties and the patient 

July 15, 1893. 

Original Articles. 


was discharged recovered on January 31, 
1893. She remains well at the date of 

At the time when I began this work I 
was simple-minded enough to think 
that the restoration of an insane- 
woman's mind was an object desiraole 
in itself, even if it involved the 
loss of organs so unessential to physical 
life as the ovaries and [f allopain tubes, and 
especially when these were in a state of 
disease. It seems however that certain 
influential members of the medical and 
legal professions regarded this as a grave 
and dangerous error and believed it a 
public duty to endeavor to check similar 
work which had been begun with encourag- 
ing success in one of the insane hospitals 
of Pennsylvania. The objections urged 
were based upon misconceptions of the 
scope and character of the work. The 
weightiest argument against it was an offi- 
cial legal opinion which pronounced it 
'^brutal and inhuman, and not excusable 
on any reasonable ground.'^ It was 
further declared to be " illegal and unjus- 
tifiable " and to subject the surgeon to 
^' the risk of a criminal prosecution.^' 

These declarations, coming from a law- 
yer of high standing, led me to pay some 
attention to this view of the question, and 
I sought by conversation and correspond- 
ence with leading lawyers of my own 
State, to learn what principles of law, in 
the absence of specific legislation, had 
any bearing upon the matter. The ques- 
tion in its specific form seems never to 
have been adjudicated in any court of rec- 

In the case of a sane person, courts 
have uniformly held that if a surgeon pos- 
sesses ordinary professional knowledge, 
exercises ordinary skill, and uses ordinary 
care in the management of his case, no ac- 
tion of malpractice can lie against him. 
It is, of course, presumed that, in case of 
an operation, the consent of the patient 
shall first have been obtained, both parties 
acting in good faith, and the patient un- 
derstanding the object and character of 
the operation. As a matter of course, 
likewise, any operation for a criminal pur- 
pose, even though with the consent of the 
patient, would not be justified by the 
courts. Here, as elsewhere, the law is 
guided by common sense — in the words of 
an eminent member of the Illinois judici- 
ary, "The law is common-sense.'" The 

only medico-legal questions, therefore, 
which seemed to me to apply here were 
such as had relation to what constitutes 
valid consent. 

With this view I drew up three ques- 
tions and submitted them to one of the 
professors in the Law Department of the 
University of Maryland. The answers 
which follow are clear and comprehensive, 
and seem to me to require no further com- 

Baltimoee, Md., March 6th, 1893. 
Dr. George H. Rohe, Catonsville, Md. 

My Dear Doctor: — After considerable 
investigation I am prepared to answer the 
several questions submitted to me by you 
in your letter of February 17th. 

"1. Is an insane person, having lucid 
intervals of greater or less duration, com- 
petent in law to consent to a surgical 
operation upon his or her body, the result 
of such operation being removal of certain 
organs or members not essential to life or 
health r 

During a lucid interval a lunatic is, in 
the eye of the law, sane. 19th. Cent. L. 
J. 427. 

The act of a lunatic, during a sane in- 
terval, has in law the validity of the act 
of a sane man. 

Pope Law of Lunacy, 18. 

Am. & Eng. Enc. of Law, Yol. 2. 112. 

Buswell on Insanity, Sec. 17. 

I answer, therefore, in reply to the first 
question that a lunatic, in a lucid interval, 
is as competent to consent to a surgical 
operation of any kind as is any person. 

Of course, you readily understand that 
great care is necessary in determining 
whether or no the consent is given when 
there is an actual lucid interval, and the 
law cannot relieve a physician from the 
responsibility of exercising this care. 

''' 2. In case the person above describ- 
ed is incompetent to legally give consent 
for the performance of such operation, 
can the recognized, natural or legal guar- 
dians of such persons give consent des- 
cribed ?" 

According to the theory of law, the 
State, acting through courts of equity, is 
the guardian of all insane persons, both as 
to their persons and property. The 
equity court appoints a committee as its 
agent for the discharge of this duty. Such 
committee is the legal guardian of the 
person, and has the power to consent to 


Original Articles, 

Vol. Ixix 

such measures as may be for the lunatics 

Pope Law of Lunacy, 111. 

Md. Code, Art. 16, Sec. 96. 

Eebecca Owings case. 2 Blands Chan. 

1 "answer, therefore, that the commit- 
tee of a lunatic is competent to give con- 
sent for the purposes mentioned, assum- 
ing, of course, that he and the physician 
act in good faith. 

The law does not recognize any such 
person as a natural guardian to a lunatic. 
The father, and, if he be dead, the 
mother, is the natural guardian of an in- 
fant, but the term is not applied to those 
who have control of persons non compos 

"3. In case a person is always en- 
tirely insane have the natural and legal 
guardians the right to give the consent 
described ?" 

I answer on the authorities cited in the 
answer to the previous question that the 
committee of an insane person has the 
right to give the consent. 

I may further add, that, even though 
the committee may refuse, an application 
to the court of equity, which appointed 
the committee, would be entertained, and 
it would be competent for the court to 
give the consent. 

"4. In case neither the patient 
himself, or herself, or his or her 
guardians, are competent to give 
the consent described, has the attend- 
ing physician the power legally to decide: 
that an operation, as described above, shall 
or shall not be performed. In other words 
Dare a physician perform an operation on 
an insane person if the latter has no rela- 
tives living or known ?" 

In answering this question it is impor- 
tant to bear, in mind that no person can 
be confined until he has been adjudged in- 
sane by proper proceedings, or unless he 
be dangerous to himself and others. 

Pollock on Torts, 108. 

Eebecca Owings case, 1 Blands Chan. 

Fletcher vs. Fletcher, 28 L. J. Q. B. 

Anderson vs. Burrows 4 C. & P. 210. 

Lock vs. Deane 108 Mass. 120. 

Underwood vs. The People, 32 Mich. 1. 

And in the case where confinement is 
necessary, because a person is dangerous 
to himself or others, the restraint must be 

temporary, and further proceedings im- 
mediately taken. 

Brown on Med. Jur. Sec. 30. 

Commonwealth vs. Kirkbride &c., 2. 
Breste, 398. 

It seems, therefore, clear that a lunatic 
with no committee cannot against his 
wishes be detained for any purpose except 
to prevent him from injuring himself and 
others, and that his confinement being for 
that purpose only will not authorize the 
performance of a surgical operation. 

I answer, therefore, that a patient con- 
fined without a committee cannot consent 
to a surgical operation, and the attending 
physician has not the power legally to de- 
cide that an operation is to be performed 
on such lunatic. 

In connection with this subject there 
are several matters to which I would call 
your attention. 

Surgical operations upon insane persons 
place the operating physician in a position 
of delicacy for several reasons. If he re- 
lies on the consent of the lunatic he is 
charged with the duty of determining 
whether the lunatic is or is not insane at 
the time of giving the consent. And it 
is probably true also that insane persons, 
who recover, are strongly disposed to hold 
persons responsible who have confined 
them for insanity, or who may have per- 
formed surgical operations on them while 
confined. Yet the law appreciates the 
delicacy of this situation. It does not re- 
lieve the physician of his responsibility, 
and of his duty to act with proper caution, 
Ifc is for this reason that the central prin- 
ciple, in the modern law of insanity, is 
that the validity of any act of a lunatic 
depends on his capacity to perform the 
particular act in question. 

People Exrel. Norton vs. N. Y. Hosp. 

3rd. Abb. N. C. 229. 

The law would, therefore, not exact so 
high a capacity in a lunatic to consent to 
a surgical operation, as it would to enter 
into a contract. 

State vs. Housekeeper, 70 Md. 162. 

Thus it has been held that a lunatic is 
capable of being a witness, although not 
capable of entering into a contract. 

3rd. Abb. N. C. 229. 

The physician himself must calculate 
the chances involved, and assume the re- 
sponsibility of the propriety of the opera- 
tion, instead of leaving this to the patient 
as in the case of a sane man. 

July 15, 1893. 

Clinical Lectures, 


Ewell on Med. Jur. 289. 

A part of the responsibility, which the 
physician must assume, is to determine 
whether the insane person has that degree 
of capacity requisite to consent. 

Before closing you will permit me to 
make some general remarks suggested by 
my reading and thought on this subject. 
The law hedges about every person with 
certain protection to his person, and it 
makes it the normal rule that no person 
can in in vitum be even touched by 
another. A fortiori, a surgical operation 
cannot be performed on a person without 
his consent. The exceptions relate to 
persons who are incapable of giving con- 
sent by reason of defect of capacity from 
infancy or insanity. In these cases the 
power is in the courts of equity to give 
the consent, and this power the court 
may delegate to guardians of infants, and 
committees of lunatics. 

There are, however, undoubtedly cases 
in which, where there is no guardian or 
committee, emergencies arise or circum- 
stances exist, which make it impracticable 
to apply to a court of equity. In these 

cases the surgeon should act with peculiar 
caution. If there are friends or relatives 
of the lunatic, he should, as far as practi- 
cable, consult with them, and he should, 
as far as practicable, avail himself of the 
judgment of other physicians. If none of 
these are available, he may in cases have 
to act on his own judgment and responsi- 

This, in my judgment, after a full read- 
ing of the subject, is clearly the position 
in which the law leaves the matter, and I 
cannot see that it would be wisdom to 
change it. If the law gave the surgeon 
greater power it might constitute a temp- 
tation to carelessness or to indulge in ex- 

It may be said that in this class of 
cases the physician is peculiarly liable to 
be sued by persons who have recovered or 
partially recovered their reason. On the 
other hand it should be borne in mind 
that the tribunals before such suits are 
tried, are fully apt to take this fact into 

Very truly, 






This patient is* an American aged 34; 
married. When fourteen she had inflam- 
matory rheumatism with chorea following. 
She has had tonsillitis every fall since 
then. Otherwise her health has been 
good until four weeks ago, when her legs 
began to swell and she had a cough accom- 
panied by considerable expectoration. Her 
father was killed in the army, her mother 
and one sister died of heart disease ; other- 
wise the family history is good. 

The history of acute articular rheuma- 
tism followed by chorea and several 'at- 
tacks of acute tonsillitis, is significant in 
connection with the fact that the patient 
has at present bruits to be heard over va- 
rious points in the praecordium. In all 

*R ecord before the Buffalo General Hospital Medical 
Clini e. 

probability the bruits were present during 
the attack of chorea. It is possible, in- 
deed common, for people to live many 
years without knowing that they have a 
valvular lesion; which is not, therefore, 
necessarily a serious thing. It becomes 
serious when, for any reason, compensa- 
tory hypertrophy of the heart does not 
occur. Aortic insufficiency is, of all le- 
sions, the most difficult to be compensated 
for ; next comes mitral stenosis. Mitral 
insufficiency and aortic obstruction are 
usually quite well compensated for, pro- 
vided the heart is well nourished and well 
innervated. These requisites can be 
brought about by maintaining the general 
nutrition and innervation of the patient 
by hygienic surroundings, regular but 
light occupation^ exercise, proper food^ 


Clinical Lectures. 

Vol. Ixix 

sufficient sleep, and avoidance of excite- 
ment and dissipation. Freedom from 
acute and clironic diseases will enable a 
heart with valvular lesion to maintain its 
equilibrium when even a slight disturb- 
ance of the general health may be enough 
to retard the xiirculation, to produce pul- 
monary and general venous congestion, 
with cough, dyspnoea, dropsy, disturbed 
digestion, enfeeblement of the mental 
powers, etc. Sooner or later there comes 
a time when the equation between the 
valvular weakness and cardiac innervation 
and nutrition is lost. This hour may be 
delayed until the patient has reached the 
natural limit of years; it may follow a 
severe fever or a period of loss of sleep, 
•overwork or excitement; it may be has- 
tened by anaemia or some other constitu- 
tional state. It may be impossible to ex- 
plain Just why the cardiac power has 
iailed at some particular time. 

During a fortnight, our patient's pulse 
has rarely been below 90, while the tem- 
perature has ranged irregularly between 
98.5° and 102°; the respirations have va- 
ried from 30 to 50. This record alone 
points to some trouble with the lungs, be- 
cause the respirations are increased pro- 
portionately to the pulse and the tempera- 
ture. We can rule out acute inflamma- 
tory diseases on account of the compara- 
tively low temperature. Eespiration 
means not simply the bellows action of the 
lungs, but the interchange of gases be- 
tween the red corpuscles of the blood and 
the cells of the tissues. The rapidity of 
respiration depends not only upon the 
capacity of the lungs to supply oxygen to 
the red corpuscles, but largely upon the 
demand of the tissues for oxygen and 
their necessity of giving off carbon dioxide. 
It is, therefore, not strictly correct to con- 
nect an accelerated breathing with pulmo- 
nary disability. The respiratory centre in 
the medulla which calls the lungs into play 
is stimulated by the presence of carbon 
dioxide in the blood. You may remember 
that, some time ago, I brought a patient 
before you with nothing wrong in the 
lungs, and with apparently well oxygenat- 
ed tissues, yet respiration was accelerated 
and this rapidity of breathing was ex- 
plained as due to Bright's disease, the re- 
tained toxines irritating the respiratory 
center. I lately saw another case of rapid 
breathing occurring in connection with 
puerperal convulsions of renal origin. In 

this case also there was no pulmonary le- 
sion. The poisons which excite the respi- 
ratory center may not cause any elevation 
of temperature. Overstimulation of the 
respiratory centre may occur independently 
of any toxaemia, and I have reported sev- 
eral cases of rapid breathing of most 
alarming appearance, in which no organic 
disturbance could be detected, and which 
yielded to remedies administered on the 
hypothesis that the trouble was a neurosis. 

But, knowing from the history of the 
case, of the existence of a cardiac lesion, 
in all probability of long duration, we 
naturally ascribe the rapid breathing to 
some pulmonary affection secondary to the 
interference with the circulation. The 
damming back of blood into the lungs is 
liable to produce oedema, as it would in 
an;^' other organ. The prolonged conges- 
tion may have established a condition of 
brown induration in addition to the oede- 

On examining this woman's lungs, we 
find rales, sibilant and sonorous breathing 
sounds — which should be spoken of as 
rales — an imperfect respiratory murmur 
at the bases ; dullness on percussion at the 
bases, becoming gradually less as we go 
upward, where the respiratory murmur 
becomes clearer. The rales and the sibi- 
lant and sonorous breathing increase as we 
ascend. There is expectoration of frothy 
mucus. On the right side the dullness 
amounts almost to flatness at the base, and 
the respiratory and voice sounds are dis- 
tant. There is undoubtedly a little hy- 
drothorax here. 

So we have to do with brown induration 
and oedema of the lungs, bronchitis and 
slight pleural effusion on one side. The 
urinary examination is negative. 

On examining the blood with the 
haemato- spectroscope, we find a clubbing 
of the oxyhaemoglobin bands in the spec- 
tral field, indicating that the blood is 
imperfectly oxygenerated . Comparison 
of the blood with the color scale indi- 
cates that there is about sixty per cent, of 
haemoglobin present. 

The heart presents a double mitral 
murmur, showing that there is both 
stenosis and regurgitation, and dilatation 
is evident from the weak and wavy cardiac 
impulse discovered to the left of the 
nipple line. 

The treatment is first to keep the 
patient warm in bed, in order to lighten 

July 15, 1893. 

Clinical Lectures, 


the labor of the heart. Dry cups should 
be applied frequently over the chest to re- 
lieve the engorgement of the lungs, and 
the surface circulation should be stimu- 
lated by frequent hot mustard foot baths 
and by diffusible stimulants if necessary. 
Why do I mention these means before 
speaking of digitalis, strophanthus and 
similar cardiac tonics ? Because it is 
better to lessen the venous engorgement 
of the organs before stimulating the 
heart; because it is better to draw the 
blood from the lungs than to force it 
through them; because by so doing, we 
not only relieve the lungs but diminish the 
obstruction offered to the right heart, 
thereby directly benefitting it. The left 
heart is also benefitted by bringing blood 
into the superficial capillaries and thus 
reducing the pressure in the larger vessels. 
There is danger in giving digitalis when 
there is weakness of the left heart, over- 
distention of the right ventricle, and 
opposition to the circulation from the 
congested organs. There is the constant 
tendency to think of what medicine we 
shall give. I want to impress the lesson 
that we must think how best to relieve a 
diseased condition without having recourse 
to drugs, by physiological means, by 
mechanical, electrical, hygenic or other 
non-medicinal treatment. In pneumonia 
and various other pulmonary troubles some, 
men advocate the use of remedies that 
deplete because, they say, you can not 
safely stimulate the heart. On the other 
hand, there is a class who say that it is 
dangerous to deplete the system. A third 
and larger class occupy middle ground, 
and advocate in the beginning depletion 
and other means that lessen congestion 
and later stimulants to sustain the heart. 

Thus the blood is coaxed or drawn 
along at first, then pushed or driven for- 
ward by digitalis or alcohol if necessary. 

The next patient suffers from a high de- 
gree of simple anaemia. By simple anae- 
mia, I mean one that does not depend 
upon any striking abnormality aside from 
that of the red corpuscles. We always 
find anaemia following malnutrition from 
any cause, such as indigestion in its 
various phases, absence of proper food, 
many acute and chronic diseases. In dis- 
tinction from simple anaemia, we find a 
class of anaemias associated with diseases 
of other organs, for example the spleen, 
liver, bone-marrow and lymph-nodes. 

These anaemias usually have peculiarities 
besides the condition of the red corpuscles. 
In simple anaemia, the red corpuscles are 
much reduced in number; they may be 
greatly increased in size and distorted. 
There is a relative increase in the number 
of white corpuscles and there may be an 
insignificant actual increase. Much light 
can be thrown on the nature of anaemia 
by studying the change in the number, 
form and size of the blood bodies. 

There is another form of anaemia that 
depends essentially not upon the changes 
mentioned but upon a fading out of the 
red corpuscles, that is a deficiency in the 
haemoglobin. This disease is called 
chlorosis because the skin of those affected 
is usually of a greenish color from the 
presence of the separated coloring matter 
of the red corpuscles. This coloring 
matter — the haemoglobin — after being 
carried in the plasma, settles in the 
various tissues of the body and undergoes 
chemical change. The liver is almost in- 
variably much darker than normal from 
the deposition of this pigment. 

This patient presents marked evidences 
of anaemia in the pallor of the face, the 
conjunctivae, the lips, the tongue and the 
gums, in short of all the accessible mucous 
membranes. Gingivitis, glossitis, con- 
junctivitis and other inflammations may 
obscure the anaemic condition of these 
membranes and, similarly, a lividity of the 
face from some obstruction to the circula- 
tion or an increase in the local blood 
supply from some disturbance of the 
sympathetic nervous system may disguise 
the pallor which we would naturally ex- 
pect. The last patient, for example, al- 
though suffering from a diminution of 
haemoglobin to the extent of 40 per cent., 
presented no marked pallor, but on the 
contrary some lividity. Thus the color of 
the skin and mucus membranes can not 
be relied upon as strictly diagnostic of the 
richness or poverty of the blood in all 
cases. But when marked pallor is present 
in connection with other symptoms, the 
diagnosis may be made quite positively. 
This patient is short of breath, her pulse 
is rapid, especially after exertion, and 
even the excitement of appearing in clinic 
is not sufficient to cause a flushing of her 
face, in spite of the acceleration of the 
pulse. In the absence of organic disease 
of the heart, lungs and other viscera, such 
as were found or suspected in the first 



Vol. Ixix 

patient, we must explain the acceleration 
of the pulse and respiration with reference 
to the condition of the blood. You re- 
member that true respiration is carried on 
by the aid of the red blood corpuscles. 
In this case these carriers of oxygen are 
deficient in number and when the patient 
makes an exertion or becomes excited or 
in any other way calls for an activity of 
some organ, there is a demand for oxygen 
which can be supplied only by hurrying 
the red corpuscles through the vessels so 
that they may become recharged with 
oxygen in the lungs more frequently. 
Bearing in mind the importance of oxygen 
as a nutrient, you can readily understand 
that a deficiency of it, such as is inevitable 
in anaemia, will lessen the activity of every 
organ. There is commonly a sense of 
languor and an inability for mental exer- 
tion, there is a failure of the digestive 
power and the bowels are usually consti- 
pated. There is often a suppression of 

menstruation, which is conservative, "since 
the body can ill afford a loss of blood. 
Even when the menses are not suppressed, 
as in the present case, they are deficient 
in color and usually scanty. For some 
reason that is not very clear, anaemia, es- 
pecially when of high grade, is usually at- 
tended by a slight rise in temperature. 
This patient's chart shows a range between 
98° and 101.5°. In special forms of 
anaemia, the temperature curve is quite 
typical, as in the intermittent temperature 
of leucocythaemia. In simple anaemia, 
the urine is usually highly acid, which is 
true in this instance. There has been 
considerable improvement in the last 
week, largely on account of treatment by 
iron. The girl has had one grain of 
Blaud^s pills three times daily after eat- 
ing. She is also taking alkalies, for 
in anaemia it is important not only to pro- 
vide iron but to increase the alkalinity of 
the blood. 



R. W. REYNOLDS WILSON, Philadelphia. 

Post-partum hemorrhage is followed by 
a series of consequences dependent upon 
thrombosis. The most conspicuous of 
these are phlegmasia alba dolens and pyae- 
mic infection, although a general infec- 
tion dependent upon the same cause is to 
be observed, as demonstrated by the histo- 
logical study of the subject. In normal 
involution the contraction and retraction 
of the uterine muscle is sufficient to pre- 
vent bleeding from the sinuses by causing 
an approximation of the vessel walls. In 
the absence of normal uterine contrac- 
tions, dependent upon want .of muscular 
development, or upon loss of blood, as in 
placenta praevia, or upon over- distention 
from twins, or hydramnios, hemorrhage is 
prevented by the formation of the throm- 
bi. On the part of the blood itself, the 

* Read before the Philadelphia Obstetrical Society, 
May, 1893. 

increase of fibrin, consequent to the loss 
of blood, is an important factor in throm- 
bosis. This natural means for controll- 
ing hemorrhage approaches a pathologi- 
cal condition, in that it admits of an ex- 
tension of the thrombi into the veins sur- 
rounding the uterus, namely, those of 
the parametrium and broad ligaments. 
In this way a direct communication be- 
tween the endometrium and pelvic veins 
is set up. 

In active involution the blood current is 
diminished, and the absorptive power of 
the veins and lymphatics is decreased, 
whereas in defective involution the amount 
of blood in the uterus increased, and the 
lympathic circulation called more actively 
into play. According to Winckel (1) the 
outcome of physiological thrombosis is des- 
cribed as a conversion of the thrombi by 
the immigration of wandering cells, pro- 

July 15, 1893. 



bably with the aid of the endothelium and 
vaso-vasorum, into a firm connective tissue 
cord, which at times becomes canaliculated, 
possibly by the passage of red blood cor- 
puscles, so that the blood current is restor- 
ed. Thus, under the conditions in which 
uterine inertia exists, we have hemorrhage 
giving rise to increased tendency to inertia 
and to the formation of thrombi, which 
serve as a dangerous means of communica- 
tion with the central venous circulation, 
and as a stimulation of the lymphatics sur- 
rounding them. Where elements of infec- 
tion are absent the thrombi shut off the 
uterine cavity from the circulation, but 
where septic material is present they offer, 
when once affected by the putrefactive 
changes about them, a means of entrance 
into the system for the micro oganisms which 
attack them. 

Bacteriological research has shown that 
the normal uterine lochia contain no 
germs, and may be injected into the body 
of any animal in any amount without in- 
jury. Doderlein (2) found that after a 
normal labor with a temperature not ex- 
ceeding 98.4° there were no germs, but 
when fever was present bacilli and cocci 
were found until the temperature fell, 
being eliminated by the very abundant 
secretion, especially when this was puru- 
lent. Micro-organisms may find entrance 
into the uterine cavity by various means, 
and when in contact with the endometrium 
give rise to infection. It has been posi- 
tively shown that the endometrium is the 
usual source of infection, for in puerperal 
ulcers of the vagina we have only a mild 
form of infection accompanying the local 
signs, and although the same micro-organ- 
isms are present as those which are found 
within the uterus in puerperal endometri- 
tis, they occur only at the seat of infec- 
tion, and are not found penetrating into 
the neighboring tissues (3). 

Having, therefore, a ease of hemor- 
rhage with the occurrence of dilatation 
thrombosis and the presence of septic ma- 
terial, we have the liability of infection, 
the process attacking the endometrium 
and spreading by means of the disorgani- 
zation of the thrombi along the course of 
the veins, especially at the placental site, 
and invading the general circulation. 

It will be of interest to study the means 
by which infecting germs find entrance in- 
to the uterus. These may be present be- 
fore the occurence of labor in cases in 

which hemorrhage is likely to occur, their 
presence and the liability to hemorrhage 
being dependent upon the same cause. 
Namely, in cases of endometritis we have, 
as has been so forcilby maintained by 
Pozzi, the presence of pathogenic organ- 
isms, the prevailing species being staphy- 
lococci (pyogenes aureus, albus and ci- 
treus), and various kinds of streptococci. 
As to the part played by the uterus in 
cases of hemorrhage due to metritis and 
endometritis with the presence of the usual 
pathogenic organisms, Winckel states that 
a limited metritis, or premature fatty de- 
generation of the muscles of the pregnant 
uterus is likely to interfere with the con- 
tractile power of the affected area. En- 
dometritis having existed during preg- 
nancy, and present at the time, when uter- 
ine contraction and retraction are essen- 
tial to the arrest of hemorrhage, predis- 
pose to bleeding ; first, on account of the 
hypersemia; secondly, by reason of erosion 
of already occluded vessels from the pres- 
ence of mycotic elements; and thirdly, by 
interferencence with involution. The 
question arises, what determines the pres- 
ence of micro organisms within the uterus 
in endometritis, and why, if in any such 
case their existence is proven, should puer- 
peral endometritis and its consequences 
be the exception rather than the rule ? 
The answer to this lies in the fact that 
the tissues of the genital tract possess, un- 
der normal conditions, a power of resistance 
to the pathogenic action of the germs which 
may be present. The vitality of these 
germs becomes more and more attenuated 
as they are acted upon by the normal sec- 
retions and cellular elements of the tissues. 
This antagonism of the tissues against the 
invasion of pathogenic germs continues as 
pregnancy advances, up to the time of the 
beginning of labor. The completetion of 
labor, marked by the expulsion of the 
placenta and discharge of liquor amnii, 
affords the natural means by which the 
genital tract is flushed out, and the pos- 
sibility of the lodgment of germs is pre- 
vented. In pathological conditions, on 
the other hand, that is, in simple endome- 
tritis, in contra-distinction to puerperal 
endometritis, the mucous membrane be- 
comes infected by the invasion of germs 
which are indigenous to the genital tract. 
According to Pozzi (4) there exists in the 
genital tract of the female a zone rich in 
micro-organisms, situated at the level of 



Vol. Ixix 

the internal os. The activity of this zone 
is increased by the general debility of all 
the tissues, which reduces cellular vitality, 
or by traumatism. In endometritis the 
mucous membrane becomes infected from 
this source, and the ordinary lesions and 
symptoms follow. In puerperal endome- 
tritis we may, in cases where hetero-infec- 
tion may be excluded, ascribe the condition 
to an ante-partum infection dependent 
upon an earlier endometritis, the earlier 
pathological changes in the uterine mucosa 
and connective tissue predisposing to 
hemorrhage, by interfering with contrac- 
tions, with infection of the resulting 
thrombi by the germs which are already 
present. In cases of atony from other 
causes (want of muscular development, 
over distention) the treatment which is 
used to avert the hemorrhage, and the 
necessary manipulations, may be respon- 
sible for the infection. Frequent exami- 
nations during the course of labor, hasty 
and careless manipulations at the time 
when the patient is bleeding, and careless- 
ness of the principles of asepsis owing to 
the loss of self-control on the part of the 
attendant, and the introduction of infect- 
ed instruments, all contribute to the risk of 
infection. There exist, therefore, under 
these circumstances, ample opportunities 
for the invasion of bacteria. 

What, on the other hand, are the natu- 
ral means of resisting these bacteria in 
cases of non-infection, and what are the 
local changes in septic cases, resulting 
from the action of micro-organisms? 
Immediately after the expulsion of the 
placenta the uterus contracts and obliter- 
ates the cavity recently occupied by the 
ovum. This contraction is influenced 
largely by the nervous condition of the 
woman, and may be considered as an 
active process. Under normal circum- 
stances the innervation of the organ pro- 
duces the active power of contraction ir- 
respective either of the elasticity of the 
fibres or of the diminution due to shorten- 
ing of the fibres by retraction. The blood 
supply is lessened by this contraction, and 
the vessels at the placental site are com- 
pressed by the uterine fibres and emptied 
of blood. Both the free contents of the 
uterus, namely, blood and the remaining 
amniotic liquid, and the adherent shreds 
of decidua are expelled. As soon as the 
tonic contractile power of the uterus is 
established, retraction of the muscle (fatty 

degeneration of the muscular fibres) and 
regeneration of the mucous membrane 
take place. Together with the lessening 
in size of the uterus by retraction, there 
is an increase in the development of intra- 
glandular tissue and a reconstruction of 
the mucosa from the epithelium springing 
from the remaining glands. The exuda- 
tion which accompanies this process, to- 
gether with the migration of white cor- 
puscles and the secretion from the cervical 
canal, constitute the lochial discharge. 
As to the local changes occurring in the 
course of infection, we have these normal 
processes modified as follows : First, as a 
predisposing cause of infection we have 
the absence of uterine contraction. As 
a result, the hemorrhage from the sinuses 
is controlled, not by pressure, but by 
thrombosis; secondly, the uterus contains, 
also incident to the absence of contraction, 
remnants of decidua, or placental debris, 
these, together with the thrombi projec- 
ting from the placental site, act as foreign 
bodies, and are prone to putrefactive^ 
changes; thirdly, the reconstruction of 
the mucous membrane is replaced by 
necrosis of the epithelium and basement 
membrane ; fourthly, the normal constitu- 
ents of the lochial discharge are replaced 
by the putrefactive debris of disorganized 
thrombi, the remnants of decidua and 
necrotic mucous membrane, mixed with 
the various micro-organisms which accom- 
pany these putrefactive changes. In 
order to appreciate the relation of such 
changes to the development of infection, 
it will be necessary at this point to study 
the histology of puerperal endometritis. 

According to Bumm we have commonly 
to deal with the following forms: 

Putrid Endometritis. — In this form 
putrefaction occurs from the presence of 
saprophytic organisms. The bacteriology 
of this condition is still undeveloped ; as 
to the histology, we find that the ne- 
crotic decidua is cut off by a zone of cellu- 
lar infiltration, by which the various mi- 
cro-organisms present are prevented from 
penetrating into the underlying tissues. 
Invasion of the thrombi, however, at the 
placental site, is not prevented by any 
such zone of reaction on account of the 
want of organization of the thrombotic 

Septic Endometritis, occurring in two 
forms. — First, a localized septic process 
in which a granulation zone occurs (con- 

Julv 15, 1893. 



trary to what is found in the form men- 
tioned above), shutting off the necrotic 
endometrium and preventing the invasion 
of germs. The uterine lymphatics are 
not actively involved. The placental site, 
as in the putrid form, is most markedly 
affected. Secondly, a septic endometri- 
tis, accompanied by a general infection. 
Bumm has studied five cases belonging to 
this class, and has found in three in- 
stances that infection has occurred by in- 
. vasion through the lymphatic system, and 
in two instances along the course of the 
veins. In the first set of cases, the pla- 
cental site is free from micro-organisms 
and thrombi, so that it is not likely that 
this pathological condition bears upon 
that form of infection resulting from 
hemorrhage in which thrombi, especially 
at the placental site, occur. In the sec- 
ond set of cases, the smaller lymphatic 
branches surroanding the sinues are 
marked by colonies of cocci, which extend 
into larger lymphatics underlying the per- 
itoneal covering of the uterus. The deci- 
dua is disorganized and infiltrated with a 
fibrinous exudate, presenting a diphthe- 
ritic appearance. In this class of cases, 
as well as in that about to be described, 
the granulation zone is absent. This fact 
has evidently an important bearing upon 
the function of such a zone of demarka- 
tion, in combating the progress of micro- 
organisms into the underlying tissue. 

Thirdly, a thrombotic form of infection ; 
and this is the form which concerns us 
principally in the discussion of post-hem- 
orrhagic infection. This is characterized 
by both a putrid and septic endometritis. 
It is described by Bumm as follows : 

" The decidual layer of the uterine cav- 
ity, in a state of necrosis, is beset with 
micro-organisms. In the neighborhood of 
the colonies of streptococci, outlined by 
the staining process, are scattered innumer- 
able colonies of putrefactive germs. The 
histological relations of the tissues — that 
is the decidual, glandular, and muscular 
tissues in the necrotic area — is unrecog- 

The zone of reaction is marked. The 
placental site presents no remains of the 
placenta, but is marked by the projection 
of thrombi. The latter are found to be 
infected by various pathogenic germs, are 
disorganized, and offer, by reason of their 
disorganization, a direct means of entrance 
for the septic products into the current of 

the blood. The disorganization occurs 
first in the axis of the thrombi. The en- 
dothelium and the vessel wall become rap- 
idly affected and break down into a mass 
of necrotic tissue mixed with white cor- 
puscles and infected with cocci and ba- 

In conclusion, we may summarize the 
development of infection as a result of 
thrombosis by noting the following events : 
First, a predisposition to infection arising 
in cases of hemorrhage the result of atony 
of the placental site; secondly, the forma- 
tion of thrombi which offer, on account of 
their want of vital organization, an im- 
proper means of resistance to infecting 
germs; and thirdly, the presence of infect- 
ing material either from the pre-existing 
endometritis or from contamination at the 
time of delivery by careless or frequent 
examinations. When these factors are 
present we have a resulting infection oc- 
curring in accordance with the histologi- 
cal changes described above. 

Clinically we are apt to consider pyae- 
mia as the type of infection occurring as a 
result of thrombosis. Such a view is 
based upon, first, the frequency of the oc- 
currence of phlegmasia following phlebi- 
tis, either by extension from the veins of 
the broad ligament or by the lodgment of 
coagula washed from the placental site and 
carried into the hypogastric veins and ob- 
structing the flow of blood through the 
crural veins ; and, secondly, upon the oc- 
currence of embolism from the detach- 
ment of thrombi from the placental site 
or the parametrium. But it is more likely, 
from the histology of endometritis in the 
puerperal state, that the thrombi act more 
as a channel by which pathogenic germs 
find entrance into the organism than as a 
direct means of conveyance by their de- 
tachment and circulation in the blood-cur- 
rent. We have observed in the thrombotic 
form of endometritis that the disorganiza- 
tion of the thrombi is a pathological 
change dependent upon the action of bac- 
teria, and that the natural barrier to the 
entrance of infecting elements is removed 
by this process of disorganization. Ac- 
cording to this, the blood -current is likely 
to be contaminated, not by the remnants 
of uterine coagula, but by the presence of 
pathogenic bacteria and their chemical 
products. These, carried alocig in the 
blood- current, may be reasonably supposed 
to set up inflammatory changes, causing 



Vol. Ixix 

phlebitis, and especially to produce tlie 
development of a general septicsemia. 
There is no doubt that the formation of 
emboli is a common result of the detach- 
ment of thrombi from the placental site, 
but, in the study of the subject from a 
histological point, we are not warranted in 
accepting the occurrence of pyaemia as the 
universal clinical associate of thrombotic 
infection the result of hemorrhage, and, on 
the other hand, we are warranted in assu- 
ming the possibility of a marked state of 
septic endometritis occurring after hemor- 

rhage without the early association of py- 
aemic symptoms. 


(1) Witickel: Lehrbuch der Geburts- 
hiilfe, 1889. 

(2) Doederlein: Centr. f. Gynsek., 1888, 
Nos. 23 and 28. 

(3) Bumm: Archiv f. Gyn., Bd. xxiii,p. 

(4) Pozzi: Medical and Surgical Gyne- 
cology, translated by Brooke Wells, M.D., 




EDWARD P. DAVIS, M. D., Philadelphia. 

It is my purpose to. night to report the 
clinical histories of these cases, inviting 
discussion upon them by the members of 
the society. 

Case I, of large ovarian cyst, oc- 
curred in the person of Mrs. V , aged 

55 years, seen by me in consultation for 
an abdominal enlargement. The history 
of the case was briefly as follows : The pa- 
tient had been of extraordinary muscular 
development; by occupation a market-wo- 
man, she had enjoyed exceptionally robust 
health. At a time not accurately de- 
scribed by herself and family, she first 
noticed an enlargement of the abdomen ; 
this must have been three or four years 
before I saw her. This enlargement was 
painless, slowly increasing, and had been 
variously diagnosticated as dropsy and tu- 
mor. The diagnosis of ovarian cyst had 
not been stated to the patient, although it 
may have been made by some of the nu- 
merous physicians who saw her. 

When I first visited her she was under- 
going treatment for the relief of dropsy, 
this treatment consisting in the adminis- 
tration of a diuretic mixture and the oc- 
casional employment of purgative medi- 
cines. On examination, the patient was 
markedly emaciated above the sternum; 
her thighs were moderately swollen, her 
legs less so than her thighs ; her arms were 

*Read before the Obstetrical Society of Philadel- 
phia, May 1, 1893. 

wasted. Her expression was not markedly 
cachectic, and a typical ovarian face was not 
clearly developed. Her pulse varied from 100 
to 110; her respiration was not noticeably 
difficult; she was cheerful, complaining 
of no pain, but of the increasing load and 
drain upon her muscular strength, occa- 
sioned by the abdominal enlargement. 
She was unable to lie down, resting in a 
partly reclining posture, usually on the 
right side. She could not sit upright, as 
the abdominal enlargement had descended 
so far as to protrude between her thighs. 
She was taking a fair am^ount of nutri- 
ment, and complained of no pain. She 
strongly desired to know the nature of her 
disease, and, if possible, to have the size 
of the abdominal enlargement decreased, 
or the condition radically remedied. 

A superficial examination of the abdo- 
men by palpation, and a partial vaginal 
examination, convinced me that a positive 
diagnosis could not be readily made under 
the circumstances in which I found the 
patient. She was accordingly told that it 
would be unjustifiable to even puncture 
her abdomen in her own house, and that 
a proper diagnosis and treatment of her 
condition could only be obtained in a hos- 
pital, where antiseptic precautions wera 
possible. She was accordingly brought 
to the Polyclinic Hospital sometime after- 
ward, it being necessary to place her in a 
partially recumbent position, in a wagon 
to transport her to the hospital. 

July 15, 1893. 



She was there examined by my col- 
leagues, Dr. Baer and Dr. Morton, and by 
my friend, Dr. George E. Shoemaker. 
The following condition of the abdomen 
was observed: 

Its enlargement was very great, and is 
best shown by the photographs done by 
Dr. White, of the resident staff, which I 
show to the Society. The skin of the ab- 
domen was brawny and thickened, and at 
the first sight simulated closely some of 
the hypertrophies of the integument occa- 
sionally seen; indistinct fluctuation was 
obtainable upon the left side of the abdo- 
men, while at the right and upper portion 
a sensation of greater resistance was detec- 
ted. Vaginal examination was negative, 
as the tumor descended so far externally 
that it was very difficult to make a satis- 
factory investigation. It was learned 
from the patience's daughter that she had 
had, in the preceding few months, several 
attacks of syncope, which had occasioned 
considerable anxiety among the family. 
A diagnosis was made of probable ovarian 
cyst, and an exploratory incision, and, if 
practicable, the removal of the tumor, 
were advised. The patient's family were 
informed that her death in a short time 
was unavoidable if she was not relieved ; 
that the chance of saving her life was 
questionable, and that the only relief lay 
in surgical interference, probably of a rad- 
ical nature. It was observed that the 
patient retained remarkable muscular 
power, being able to partially raise herself 
and move about upon her bed in a manner 
indicating her former strength of phy- 
sique and constitution. She and her fam- 
ily consented to the operation, and after 
suitable preparation, with the assistance 
of Dr. Shoemaker, Dr. Morton and Dr. 
Baer, the abdomen was opened. 

To place the patient in position for 
operation it was necessary to provide an 
additional table for the tumor. As she 
could not lie upon her back she was turn- 
ed upoa her right side, the tumor lying 
upon a small table. As syncope was 
feared, oxygen was at hand, and an electric 
battery and various stimulants. It was 
determined to mitigate the tremendous 
change in the physical conditions of the 
circulation, which the emptying of the 
tumor would produce, by removing the 
contents as slowly as possible, making con- 
tinuous pressure during this time. An in- 
cision through the abdominal wall revealed. 

as was expected, the sac of a cystic tumor. 
This was punctured by a trocar, when a 
large amount of chocolate- colored fluid 
escaped. More than a half hour was con- 
sumed in emptying the fluid, the patient 
meanwhile enduring the operation fairly 
well. The cyst was but very slightly ad- 
herent to the wall of the abdomen, and it 
seemed quite possible to completely remove 
the tumor; accordingly, the tumor was 
separated from the abdominal wall. It was 
found to be a multilocular cyst, its largest 
portion lying beneath the liver. The solid 
parts were broken down as rapidly as pos- 
sible, and the entire mass removed. Its 
pedicle was from the right ovary, and was 
so small as to scarcely require ligation. No 
adhesions calling for ligature were found, 
and the hemorrhage which accompanied the 
separation of the cyst was inconsiderable. 

The patient partially collapsed during 
the removal of the solid portion^ but was 
relieved by inhalations of oxygen and the 
use of an electric battery, accompanied by 
the injection of stimulants. The removal 
of the tumor demonstrated the great 
changes which its enormous size had caus- 
ed in the body of the patient; the lower 
ribs had been turned outward and upward, 
and the distended abdominal walls lay in 
folds against the spinal column. 

As quickly as possible the abdominal 
cavity was freely flushed with a hot saline 
solution, the incision closed and large 
masses of cotton were bandaged firmly 
above an antiseptic dressing. The patient 
reacted from the operation, her tempera- 
ture being 97.5° and then 98°; her pulse 
120 and 130. She became conscious and 
complained of no pain. Six hours later, 
without appreciable warning, she died in 
sudden syncope. 

No post-mortem examination could be 
obtained, but symptoms of hemorrhage 
were never present. The condition of the 
patient's kidneys and bowels was normal 
before and after the operation. 

The solid portion of the tumor weighed 
nine pounds; seventeen gallons of fluid 
were collected during the operation, the 
weight of the fluid being 17-^ ounces to the 
pint. The total weight of the solid and 
liquid portions of the tumor reached the 
great total of 160 pounds. Microscopic 
examination of the fluid showed choles- 
terin and hsematin, blood cells and anom- 
alous epithelia. No measurements were 
made of the tumor before its removal, as 



Vol. Ixix 

the patient's condition was such that I 
limited manipulation and disturbance of 
her position to the interference necessary 
in securing an examination for diagnosis. 

The question of practical interest sug- 
gested by this case lies in the avoidance 
of the syncope which destroyed the pa- 
tient's life. Is it possible to remove so 
large a mass from the abdominal cavity 
without producing such a change in cir- 
culation as to cause fatal syncope ? Two 
methods of treatment were available one. 
the partial emptying of the cyst, stitching 
its wall to the abdominal wall and using 
drainage ; the second was the complete re- 
moval of the cyst as practiced. Had firm 
adhesions been present, no effort would 
have been made to remove the tumor ; it 
would have been partially emptied, with 
the hope of prolonging the patient's life 
by the operation. The fact that the 
tumor could be separated without great 
difficulty from the abdominal wall led us 
to practice total removal, believing that 
the patient's chance of ultimate recovery 
would be sufficient to warrant the proced- 
ure. We were led to operate upon the 
case by the patient's desire for relief, by 
the threatening syncope from which she 
had already suffered, and by her remarka- 
ble and persistent strength, and her pre- 
vious history of uniformly good health. 

Case II is an example of abscess over 
the coccyx without appreciable cause, and 
accompanied by pain at the sacro-coccy- 
geal joint, completely relieved, first by 
evacuation of the abscess, and then by ex- 
tirpation of the coccyx. The patient, 
Mrs. B., was first seen in the eighth 
month of her first pregnancy; her health 
had been good; her pelvis was normal; 
the foetus occupying the second position, 
its heart-sounds were plainly discernible. 
She complained of a painful swelling to 
the left of the coccyx and above the junc- 
tion of coccyx and sacrum. This swell- 
ing gave indistinct fluctuations, and was 
painful upon pressure. On vaginal exam- 
ination, pressure upon the coccyx revealed 
great tenderness, also to the left of the ar- 
ticulation with the sacram. She stated 
that, three months previously, a similar 
swelling had appeared, which was dissi- 
pated without treatment. She said that, 
before her marriage she had h^Qn fond of 
riding, but at times had been obliged to 
dismount by reason of pain in this region. 
When asked if she could recall a bruise. 

fall, blow, or direct injury to the part, she 
could not do so. Under antiseptic pre- 
cautions the tumor was incised, emptied of 
an ounce of foul, sanious pus, and a care- 
ful examination with the finger and probe 
was made to detect caries of the bone. 
This was apparently absent, a smooth cav- 
ity only being found. K pyogenic mem- 
brane was curetted away, the cavity irri- 
gated and packed with gauze. Uninter- 
rupted recovery followed. 

At the patient's labor she experienced 
marked pain when the head reached the 
pelvic floor. Her child, a female, was 
small, and the delivery was readily accom- 
plished under ansesthesia by chloroform. 
Her puerperal period was marked by no 

Five months after her labor she request- 
ed further relief for pain in the coccyx. 
Previous to her marriage she had been a 
trained nurse, understood the details of 
surgical operations, and desired to avoid 
any such procedure if possible. I could 
detect no hysterical element in- the case, 
but the patient and her husband were con- 
vinced that treatment was requisite. 

On vaginal examination the gential 
tract was found in a normal condition ; 
the patient's general health was excellent; 
the position of the uterus was normal, but 
pressure upon the cervix gave rise to an 
indistinct, grating sensation and to the 
complaint of acute pain upon the part of 
the patient. The coccyx was accordingly 
removed, and found to be of normal length 
and dimension. The articulation between 
the sacrum and coccyx was slightly rough- 
ened, but no evidence of caries, necrosis, 
or suppuration could be found. The scar 
of the previous abscess was firm, and the 
abscess had been completely obliterated. 
The patient was entirely relieved by the 
removal of the coccyx, and continues in 
good health. 

The interesting point in regard to the 
case is an explanation of the occurence of 
this abscess when the history of no spetic 
infection could be obtained. The usual 
causes of abscess in this region are violence, 
sinus, or fistula connecting with the in- 
testine, and septic infection of the genital 
tract, septic infection after labor, accom- 
panied by mechanical injury to the parts ; 
by the foetus, or the instruments used by 
the obstetrician. The most rational ex- 
planation of this case is afforded by the 
interesting examples found in surgical 

July 15, 1893. 



literature, where abscess cavities without 
communication with surrounding parts 
have been observed in this region of the 
body, as the result of a persistence of the 
foetal medullary canal. Most of these cases 
occur in males, and hair is found in these 
cavities. The continued irritation of the 
parts by pressure has explained a non-septic 
necrosis which results in the formation of 
abscess in this region. In many of these 
cases an external opening is found near 
the coccyx, admitting a small probe from 
which a sinus proceeds along the walls of 

the intestine. Pavement epithelium is 
often found upon the walls of these cysts 
when hair is not present. Oases similar to 
that reported have been reported by 
Terrillon, Goodsall, Warren and Beach. 
An interesting research upon this subject 
is that by Mallory, of the Harvard Medical 
School, published in the American Journal 
of the Medical Sciences for March, 1892, 
page 263. The relation of such sinuses 
and cysts to the coccyx is well shown by 
Mallory in reproductions of microscopic 
sections through embryos of various ages. 


"W. H. LINK, M.D., Petersburg, Ind. 

Having lately passed some three months 
in Philadelphia, studying the materials, 
methods and results that obtain among 
the great surgeons of this city, I shall 
try, through the medium of the Repor- 
ter, to set forth the advantages and dis- 
advantages of Philadelphia as a place for 
post-graduate study for those men of the 
West and South who every year migrate 
toward the great medical centers of the 
country seeking the latest and the best in 
both medicine and surgery. 

In the first place Philadelphia is cheap. 
Both board and lodging are exceedingly 
low. One can find good accommodations 
ranging from 14.50 to 16.00 per week. 
Instruction is given at moderate prices. 
To a man of wealth these things would 
be of no special importance; but the 
average country doctor is not noted for 
the large and increasing size of his 
bank account, and the meanest thing 
about him is his income. The length of 
his stay will thus depend largely upon 
the cost of living. 

Philadelphia offers superior advantages 
for the study of abdominal surgery. In 
this branch she excels. There is not a 
man in her confines doing abdominal sur- 
gery as a specialty who is not a superior 
operator and teacher. The abdominal 
surgeons, too, takp. great delight in show- 
ing their work. Every facility for close 
and accurate observation is offered visit- 
ing physicians. The amount of material 
is apparently inexhaustible. If one will 
-arrange his engagements properly, he may 

see from three to ten sections a day. In 
a twelve- weeks' course he can see the whole 
field of abdominal surgery covered — tu- 
mors, pus cases, hysterectomies, liver sur- 
gery, gut work, hernias, anything and 
everything to which pelvic and abdomi- 
nal surgery comes for relief or cure. 

If one stays in Philadelphia three 
months and takes advantage of his op- 
portunities, and then goes home and fails 
to do good abdominal work, it will be due 
to defects inherent in himself rather 
than to a want of good and sufficient 

The general surgery of Philadelphia, 
taken as a whole, is not so good as that 
of the gynecologists, and a great many 
of the general surgeons manifest but lit- 
tle desire to have their work observed. 
There are, of course, brilliant exceptions 
to this rule, which I will notice further 

The Polyclinic has two admirable sur- 
geons on its staff, who do a large amount 
of work, and as the classes are usually 
small at any one time, attending physi- 
cians have abundant opportunity to study 
each case and every operation at close 
range and master both the principles and 
diagnosis and the technique of the opera- 

Dr. B. F. Baer holds a clinic three days 
in the week at the Polyclinic Hospital, 
and always has something of interest to 
show the class. Baer's methods of teach- 
ing cannot be improved upon. The class, 
small in number, are each permitted to 



Vol. Ixix 

examine the patient, make a diagnosis 
and prescribe the treatment. He then 
discusses the case with them and corrects 
any errors that have been made. If an 
operation is indicated^ the class get a close 
view of the work and are thus permitted 
to study the case both from below and 
above. The old speculum system of 
teaching, or the Ferguson peep-show, has 
no place with Baer. As an operator, Baer 
holds an enviable position. His results 
are very good, and he throws open the 
wards of the hospital and invites inspec- 
tion of his cases in their convalescence. 
Baer has some ideas of his own, which 
place him in a solitary position among the 
abdominal surgeons of Philadelphia. 

He opposes drainage^ as a rule, and he 
undoubtedly practices what he preaches. 
He very rarely drains. I saw him remove 
huge pus tubes and ovarian absceses during 
which the pelvic cavity was bathed in 
great quantities of pus. He irrigated 
carefully and closed without drainage. 
The patient made a prompt and painless 
recovery. He also gives morphia if his 
section cases suffer pain. He does a su- 
pravaginal hysterectomy, which is a most 
beautiful operation to look at. The ope- 
ration consists in tying off the ovarian 
and uterine arteries, cutting the uterus 
away at the crevix and covering the re- 
tracted stump with the peritoneum by 
means of a few Lembert sutures. The only 
question about the operation is its mortal- 
ity. He has twenty-seven cases with two 
deaths. If he can keep his mortality this 
low it will compare favorably with the op- 
eration by the nceud and give a quicker 

What one sees in Baer to approve, are 
his self-reliance, his courage, his thorough- 
ness, his practical methods of teaching 
and his splendid results. To appreciate 
him at his worth, one should see him oper- 
ate often. At first, he seems to be inde- 
cisive, hesitating, but as you see more of 
him, you find that what appeared to be 
nervousness and vacillation is only a spe- 
cies of somnambulism in which he merely 
thinks aloud and goes on with the work 
while talking to himself. His underlying 
strength and skill soon rise to the surface 
and when the work is complete you behold 
in the finished product a conquest that 
bespeaks a master. There are some minor 
things in Baer^s technique that one might 
criticise, but, in the face of such splendid 

results as he shows, criticism seems akin to 
carping, so I refrain. 

Dr. J. M. Baldy operates at both the 
Polyclinic and G-ynecean Hospitals. 
His work is ta be commended for his 
faultless technique as to asepsis and his 
boldness as an operator. He is very cool 
and collected and does not lose his head 
however trying the complication that may 
arise. Baldy is especially free from hob- 
bies. He does good plastic work and I 
think shows good sense in doing Emmet's 
operation on the perineum without attemp- 
ting to spoil a most beautiful and perfect 
piece of surgery by some modification of 
his own. We have yet to see anyone mod- 
ify Emmet's works who did not convince 
us that the modification greatly marred 
the beauty and efficiency of the work. 
Baldy is one of the most fluent talkers at 
the Obstetrical Society and as a writer and 
teacher he makes himself easily under- 
stood. As to his results I cannot speak, 
as I saw none of his cases after operation, 
but presume that they are good, for his 
surgery was both clean and skillful. Both 
Baer and Baldy are warm admirers of the 
Trendelenburg position. They use it in 
most of their work and certainly the po- 
sition, in their hands, appears to great ad- 
vantage. In deep hemorrhage especially, 
it seems to supply a long felt want. 
Dr. Joseph Price has a daily clinic in the 
diseases of women at the Philadelphia Dis- 
pensary. He does most of his surgical 
work at his private hospital, 241 N. 18th 
St. In this hospital he has about 90 beds 
and when crowded can make room for 
one hundred beds. Besides his work here, 
he does a great deal of consultation work 
both in and out of the city. 

Large numbers of men come to observe 
Price's work. They represent every state 
in the Union and every one of the Cana- 
dian provinces. A great many stay and 
observe for a short time, whilst others take 
a course with Dr. Price of from six to 
twelve weeks. For this he charges from 
one to two hundred dollars. In this 
course the student-doctor makes a diagno- 
sis and prescribes treatment at the dis- 
pensary. If the case is surgical, he 
assists Dr. Price to operate. All the ope- 
rations are most carefully and thoroughly 
demonstrated. During the twelve weeks 
that I was with him, he did from two to 
five sections a day, and frequently as many 
as three plastic operations in one day. 

July 15, 1893. 



He is a great operator, and, what is bet- 
ter, a great teacher. His technique is the 
simplest and most perfect it has ever been 
my good fortune to observe. His diag- 
nostic skill is a marvel to those who have 
a chance to see it exercised. He operates 
for positive disease only, and not for any 
troubles that cannot be identified and lo- 
cated by the tactus. In all the numerous 
sections observed by me in his practice, I 
never yet saw him open the belly for any- 
thing but the most positive and easily de- 
monstrated disease. His skill as an ope- 
rator is so great that the work he does 
seems to the bystander easy till he tries it 
himself. He never, at any time or under 
any circumstances, loses his head or be- 
comes in the least rattled. If a trying 
hemorrhage unexpectedly occurs, the 
only evidence of its effect on him is an 
increase of moisture on his brow. He 
uses but few instruments and the leading 
characteristics of his work are simplicity 
and the most absolute cleanliness. So 
perfect is the drill that he has put him- 
self through, that when from any cause 
his hands are soiled, they appear like a 
fish on dry land and seem uncomfortable 
and instinctively move toward the water. 
He operates as a skillful musician plays 
the violin, his fingers always find the 
proper position at the right time, but it 
has been done so often that the action 
has almost become automatic and scarcely 
requires an effort of the mind and will. 
His sections now number over two thou- 
sand, while his mortality is near three per 

He has done 85 extra-uterine preg- 
nancies with one death, and his mortality 
in hysterectomies is 5 per cent. While I 
was with him he had but three deaths at 
his hospital, and saw the patients daily, 
after section, until they left for home. 
Dr. Mordecai Price, the brother of Joe, 
is also a great surgeon, whether judged by 
his knowledge, operative skill or success- 
ful results. He is now doing almost as much 
work as his brother, and is doing it just as 
well. Both of these men do a large 
amount of plastic gynecology, and while 
their abdominal work is almost beyond 
criticism, their plastic surgery is simply a 
beautif al exhibition of the surgeon's art. 
They both do Emmet^s operation on the 
perineum and believe it the best operation 
of the kind ever developed or perfected for 
the purpose. They give Emmet full credit 

for his work, and do not attempt to rob 
him of his just dues by a useless or harm- 
ful modification of their own. The fact 
is, Emmet has done for plastic gynecology 
in America just what Tait has ' done for 
abdominal surgery in England, and it 
would be much better for suffering women 
if those who offer them surgical relief 
would take the work as Emmet has per- 
fected it and not mar a really beautiful 
procedure by some fancied improvement 
of their own. The work of the Prices 
is daily increasing and they are now doing 
over 600 sections a year. This may seem 
a large amount of work, but when we re- 
member that they draw their material 
from British America to Cuba and from 
California to Massachussetts, that patients 
come to them from every State in the 
Union, it will not seem so large. They 
have no idle moments and know no Sun- 

The general surgery of Philadelphia is 
no discredit to her old-time reputation. 
But since the days of Agnew, Pancoast 
and Gross some changes have crept in. 
Then the best and most brilliant work was 
done by the old men. In fact, Agnew's 
success all came to him after 45. Now 
with probably two exceptions, Morton and 
Keen, the really valuable, original, bril- 
liant and successful work is done by the 
younger men. Eoberts, Deaver and 
White are all worthy to wear the mantle 
of any of Philadelphia's great surgical 
teachers of the past. 

Dr. J. William White is professor of 
surgery in the University. He is a natural 
teacher and no one is readier to recognize 
it than the students who sit under his 
tutelary wing. He is a clear, fluent and 
instructive lecturer. His operative skill 
impresses all visiting physicians so favor- 
ably that they desire to see all of it possi- 
ble. Dr. White is a great stickler for an- 
tisepsis ; but his antisepsis is not an excuse 
for slovenly technique, for it is joined to 
the most perfect asepsis. 

Being a personal friend and a great ad- 
mirer of Sir Joseph Lister and Mr. Fred- 
rick Treves, he believes strongly in the 
virtue of germicides but does not neglect 
cleanliness. The fact is. White's aseptic 
precautions, and the automatic exactitude 
with which he applies and observes 
them in his work, would ensure success 
in the most difficult abdominal surgery. 
In Dr. White are most happily combined 



Vol. Ixix 

the brain of a cultured surgeon and 
scholar with the body of an athlete, and to 
the mens sana in cor pore sano is added in 
the freest manner the polished manners of 
a gentleman. His kindness and courtesy 
to visiting surgeons are tireless, while 
nothing exhausts his patience. 

Should one desire to work a short time in 
a good clinic and under an able specialist 
and teacher in diseases of the nose and 
throaty he will find all that he may wish 
at the Pennsylvania Dispensary, cor. 13th 
and Chestnut Streets. The nose and throat 
department of this dispensary is in charge 
of Dr. J. L. Hammond. He is one of 
the rapidly rising young men of the city. 
He has marked diagnostic skill, and as a 

manipulator of instruments and a teacher 
of others he certainly has few superiors. 
Dr. H. while working at this specialty 
wisely devotes himself to general practice, 
and this broadens and deepens his know- 
ledge against the day when his practice 
will be so large that he will be compelled 
to confine himself to a special line of work. 
There are hospitals and*dispensaries and 
schools enough in Philadelphia to keep 
any number of post-graduate attendants 
busy from morning till night if they were 
systemetized so that hours and days would 
not conflict. But so long. as only a few 
men exhibit a desire to show their work, a 
very large amount of valuable material 
must of necessity go to waste. 


RUFUS B. HALL,t M. D., Cincinnati, Ohio. 

The best methods of treating the pedi- 
cle in abdominal hysterectomy has been a 
subject for contention for years. There 
have been two principal methods which 
have been universally accepted — the intra- 
peritoneal and the extra-peritoneal, and 
for a number of years one or the other of 
these has been recognized as the orthodox 

As we might naturally expect, there 
have been many modifications and im- 
provements in minor technique of Schro- 
der's and Pean's methods, as originally 
practiced by them. As our knowledge of 
the pathological conditions and complica- 
tions to be overcome in removing fibroid 
tumors increased, and our operative expe- 
rience became broader and more mature, 
the Pean method of extra-peritoneal fixa- 
tion of the pedicle became the one which 
was almost universally employed. For this 
reason it will be the method most fre- 
quently used in making comparison in 
this paper. The cause of the extra-peri- 
toneal method being the one most fre- 
quently employed is obvious when we re- 
call the fact that only a small percentage 
of all fibroid tumors are suitable cases for 

* Read by title at the American Medical Association, 

f Professor of Clinical Gynecology, Miami Medical 

treatment by Schroder's method, by 
those advocating it, and of these it was 
not possible to control hemorrhage in all 
cases; and, above all, the Pean method 
gave the best results. 

Those of us who have made many ab- 
dominal hysterectomies for the removal of 
large tumors know that the tumor may, 
and not infrequently does, descend into 
one of the broad ligamants and body of 
the uterus so far that we must separate 
it from its peritoneal envelope before a 
suitable pedicle can be made and fixed 
outside. Manifestly, these complicated 
cases are not suitable ones for the intra- 
peritoneal method, even by the most ar- 
dent advocates of it, and have, therefore, 
heretofore been treated by the extra-peri- 
toneal method by most operators. We 
are all aware of the fact that, if we use 
the intra-peritoneal m.ethod, we are in 
great danger of losing our patient from 
intra-abdominal hemorrhage; and, if we 
use the extra-peritoneal method, we not 
infrequently see the pedicle slough and 
become a menace to the life of the pa- 
tient for days afterwards, and not a few 
die from septic infection from that 
cause. If the patient makes a primary re- 
covery from the extra-peritoneal method 
she is not in all cases restored to health. 
She not infrequently suffers great pain. 

July 15, 1893. 



due to the pedicle dragging upon the 
abdominal scar and pressure upon the 
distorted pelvic organs interfering with 
their -functions because of the fixation of 
the pedicle. The prolonged and painful 
convalescence which necessarily follows 
this method is a very serious objection 
to it, and not infrequently a hernia fol- 
lows the operation, at or near the point 
where the pedicle was fixed in the ab- 
dominal wound. 

If we can remove these objections 
without additional risks to our patients, 
it is our duty to do so. Thanks to the 
ingenuity and skill of American gyne- 
cology, we have now a method which prom- 
ises all of the advantages of both of the 
old methods, with but few of their disad- 

It was one of these desperate cases, in 
which the operator had to '^enucleate 
large nodular masses from the broad liga- 
ment/' that induced Eastman to remove 
the entire cervix in his first total extirpa- 
tion operation. The success in that case 
encouraged him and others to continue 
making the operation, improving the tech- 
nique in minor details until it is very near, 
if not quite perfect. The procedure has dis- 
tinct merit over all other methods, and it 
is upon this basis we ask a hearing before 
the profession at this time. 

First : There is no pedicle to become 
necrotic, and thereby a source of septic in- 
fection, or fatal hemorrhage. 

Second : There is no more danger 
from hemorrhage than after ovariotomy. 

Third : There is no more raw surface 
left in the peritoneal cavity to favor intes- 
tinal and omental attachments than after 

Fourth : It is no more difificult than 
many other abdominal and pelvic opera- 
tions, and does not require any more time 
to perform it. 

In patients with thick abdominal walls 
this method promises as good results as in 
those with thin abdominal walls, which 
cannot be said of the extra-peritoneal 
method. There is no distortion of 
the pelvic organs, thus interfering with 
their functions. There is a comparatively 
painless convalescence, which is shortened 
at least two weeks under that of the extra- 
peritoneal method. 

These are a few of the advantages of 
the method as suggested to me in my ex- 
perience with it. 

There is not as much danger of hemor- 
rhage as there is in simple ovariotomy, 
from the fact that in the latter operation 
the pedicle is transfixed and ligated in 
mass ; and in not a few cases the pedicle 
is short and thick, with great tension upon 
it, favoring the slipping of the ligature 
and hemorrhage. In total extirpation 
the bi'oad ligaments are divided from the 
uterus and ligated in sections which are 
not put upon the stretch, therefore there 
is but little if any danger of a ligature 
slipping off. The ligatures do not include 
any uterine tissue, therefore the tissue 
within their grasp is not susceptible to 
undue shrinkage and resulting hemor- 
rhage. There is no raw surface left in 
the pelvic cavity after the operation is 
completed, except the ovarian stumps, to 
form attachments to intestine or omen- 

After ligating off the ovaries upon both 
sides, the peritoneum only is divided 
about one inch above the top of the blad- 
der, across the front of the tumor and at 
a corresponding heighth on the back of it. 
This is done before any temporary clamp 
is placed. The peritoneum is then 
stripped down in front and the bladder 
separated from the tumor down to the 
vagina, and the peritoneum stripped from 
the tumor behind. All of the ligatures 
required in the subsequent steps of the 
operation are placed so as not to include 
the peritoneum in their grasp. The num- 
ber of ligatures in any of my operations 
has not exceeded three upon each side 
after the peritoneum was stripped down. 
One end of each ligature securing the 
uterine arteries is left about six inches 
long, and after the cervix has been re- 
moved, is carried out through the vagina, 
and are cast off or removed through that 
passage. The peritoneal edges which 
were stripped from the tumor are now 
turned in towards the vagina and neatly 
coapted from one ovarian stump to the 
other by a running stitch, thus closing off 
entirely the raw surface in the vagina 
from the peritoneal cavity. The wound 
in the vagina is treated the same as after 
an ordinary vaginal hysterectomy. 

The difficulties attending the operation 
are not so great as one who has not at- 
tempted it would suppose, and they are 
easily and rapidly overcome by one skilled 
in performing difficult and complicated 
abdominal and pelvic operations ; and the 



Vol. Ixix 

time required to perform the operation is 
no longer than that required to make 
many of the difficult abdominal and pelvic 
0])erations now being performed daily. 

It has been said that by the removal of 
the cervix the key of the arch of the pel- 
vis is destroyed, and a weak point is the 
result, which will in a certain percentage 
of cases result in vaginal prolapses or her- 
nia. Such an accident has not followed 
the operation, to my knowledge, neither 
has it occurred after vaginal hysterectomy; 
and I do not believe it wo aid occur any 
more frequently after abdominal hysterec- 
tomy than vaginal hysterectomy, where 
the two conditions after operation are 
identically the same; and we do not hear 
of objections to the latter operation on 
that account. 

The method has stood the test admirably 
fulfilling every indication and requirement 
even better than its friends had anticipated. 
I am convinced that the method has come 
to stay, and in the near future the clamp 
in abdominal hysterectomy will as certainly 
be a thing of the past, as it now is in 

I make this assertion advisedly, know- 
ing full well that it is a radical one which 
is not likely to be readily assented to by 
many operators. In proof of my con- 
fidence in the method, I here give a short 
report of all the cases I have operated 
upon by this method, ten in number. 

Many of the cases were very undesirable 
subjects for any operation, and most of 
them proved to be complicated operations 
as you will see, thus testing thoroughly 
the merits of the method. 

Case 1. Mrs. W., aet 50. Eeferred to 
me by Dr. Joseph Eichberg of this city. 
Operated upon February 4, 1892, and a 
tumor weighing 22 pounds removed. 
There were firm and extensive adhesions to 
to intestines and omentum and abdominal 
walls, as well as in the pelvis. There was 
an abscess in the pelvic cavity holding a 
pint or more of pus. This abscess was 
ruptured and its contents spilled inside of 
the peritoneal cavity during the operation. 
Patient recovered and is now in excellent 

Case II. Mrs. P., aet 52. Referred 
to me by Dr. Means, of Troy, Ohio. 
Operated upon March 31, 1892. The 
tumor extended to one inch above the 
umbilicus. She made a rapid recovery 
and is now in good health. 

Case III. Mrs. F., aet 37. Referred 
to me by Dr. Templeton, Covington, Ohio. 
Operated upon September 11, 1892. At 
that time patient had been suffering from 
septic peritonitis for 12 days, caused by 
the strangulation of a pedunculated 
portion of the tumor the size of a small 
orange. At the time of the operation, 
pulse 138, temperature, 103°. There was 
a pint or more of dark colored fluid in the 
peritoneal cavity. The tumor was a large 
one, extending up to the ribs. The 
patient made a prompt recovery and is 
now in good health. 

CaseIY. Miss H.,^et42. Referred 
to me by Dr. J. Gr. Senour, of Troy, Ohio. 
The physician of a neighboring city re- 
moved the ovaries and tubes June 3, 1892. 
This operation failed to check the growth 
of the tumor or the hemorrhage. A few 
months after the operation the hemorrhage 
was worse than before. The tumor filled the 
entire pelvic cavity and projected well up 
into the abdomen. The operation was 
made December 2, 1892. The bladder was 
carried up almost to the top of the tumor 
and had to be dissected from it. There 
were extensive and firm intestinal adhesions 
to the left side of the tumor, correspond- 
ing to the point where the ovary had been 
removed. In the right side of the ab- 
dominal and pelvic cavities there were many 
adherent coils of intestine which were sepa- 
rated with the utmost difficulty. One coil 
was adherent behind the tumor deep down 
in the pelvis to the stump from whence 
the right ovary had been removed, and 
had to be separated by the sense of feel- 
ing before the tumor could be delivered. 
The intestine was intensely lacerated in 
liberating it. The peritoneal covering of 
the intestine at the point of injury was 
entirely stripped from it, and the adhesions 
were so firm and extensive that it was im- 
possible to trace out the intestine to a 
healthy portion so as to make a resection. 
The intestinal injury was repaired with 
sutures, but could not be brought up so as 
to make an artificial anus. The patient 
rallied well, and in three hours had a pulse 
of 70, and a temperature of 99°. But to 
my very great regret the fluid removed 
from the drainage tube had a eculent 
odor, showing conclusively that the in- 
testines at least leaked gases. The patient 
died the 5th of December from septic 
peritonitis, due to intestinal leakage. The 
death was not due to any fault of the 

July 15, 1893. 



total extirpation method, and the result 
would have been the same by any method 
of treating the pedicle, as it was plainly 
due to intestinal leakage. 

Case V. Miss J., aet 39. Keferred 
to me by Dr. Blair, Lebanon, Ohio. The 
tumor was a soft oedematous fibroid. Pro- 
fuse hemorrhage. Operation March 9, 
1893. Patient made a prompt and un- 
interrupted recovery. 

Case VI. Miss M., aet 40. Eeferred 
to me by Dr. Khu, of Marion Ohio. 
Tumor extended well into the abdomen 
and was firmly adherent in the pelvis. 
Operation March 16, 1893, after an at- 
tack of acute peritonitis of fourteen days 
duration. Patient recovered. 

Case VII. Mrs. T., set 44. Came to 
the clinic of the Miami Medical College 
for treatment. The tumor extended to 
three inches above the umbilicus. Pain 
and hemorrhage. Operation at the Pres- 
byterian Hospital, March 30, 1893. Pa- 
tient made a prompt and easy recovery. 

Case VIII. Miss S., set 39. Eeferred to 
me by Dr. Blair, of Lebanon, Ohio. 
Large, soft, oedematous fibroid of sixteen 
yearns standing. Tumor extended about 
four inches above the umbilicus. Profuse 
hemorrhage, great anaemia, and extreme 
weakness. Operation April 29. Prompt 

Case IX. Mrs. B., get. 33. Eeferred 
to me by Dr. Heaty, of Clendale, Ohio. 
Profuse hemorrhage and severe pain. 
Operation May 15, 1893. Tumor size of 
cocoanut. Double pyosalpinx and sup- 
purating ovaries with six ounces of pus 
on left side. Universal adhesions. Pa- 
tient recovered. 

Case X. Mrs. N., aet. 52. Eeferred 
to me by Dr. Dewitt, this city. Profuse 
hemorrhage for three years. Tumor ex- 
tended three inches above the umbilicus 
and was firmly fixed in the pelvis. Great 
pain and marked anaemia, and extreme 
weakness. Operation May 23, 1893. 
Extensive intestinal adhesions, large sup- 
purating ovary holding eight ounces of 
pus, which was ruptured and its contents 
spilled inside of the cavity during the 
operation. Patient recovered. 

I have heretofore been so prejudiced 
against the operation of hysterectomy that 
I have refused to operate as long as the 
patient's condition could be made tolera- 
ble. But with the present good results 
following total extirpation, I shall here- 

after advise operation earlier for fibroids. 
Considering the nature of the cases con- 
stituting this report, the results are all, 
or even more, than could be expected. 

The Weight of the Two Sides of the Brain. 

Prof. Braune, of Leipzic, has recent- 
ly published the results of weighing the 
halves of 100 human brains. These were 
divided in the median line, and the cere- 
bellum, with the medulla and pons, were 
cut off and bisected. The weight of the 
two sides of the whole encephalon were 
compared, as well as that of the cerebral 
hemispheres, and the halves of the cere- 
bellum with the medulla and pons. It 
has generally been taught that the left 
half of the brain is heavier than the fight, 
and that this is a physical cause of right- 
handedness. The results of Prof. Braune's 
investigations do not seem to bear this 
out. He found the left side of the entire 
brain heavier in 52 cases, and the right in 
47 cases, the two sides being equal in one 
case. And he also found that if the ex- 
cess of weights of the two sides be added 
up, the right side showed a preponder- 
ance, the difference between the two sides 
being in most cases so slight as not to de- 
serve any consideration. In five cases in 
which the right side considerably out- 
weighed the left, the bodies were examined 
for signs of left-handedness, but none 
were found. The left cerebral hemis- 
phere was the heavier in 54, the right in 
37 cases; while the left side of the cere- 
bellum was the heavier in 54 and the right 
in 33 cases. Thus he found that the cer- 
ebral hemisphere of one side is the larger 
about as often as the cerebellum of the 
other; but the larger halves are on the 
same side about twice as often as on 
different sides. — Boston Medical and Sur- 
gical Journal. 

An exchange publishes the following 
bill-head of a doctor in Kansas : "A prompt 
settlement of this bill is requested. If 
bills are paid monthly a discount of ten 
per cent, is allowed. Bills not paid month- 
ly will be passed to my attorney for collec- 
tion. If you pay your doctor promptly, 
he will attend you promptly, [night or day, 
rain or shine ; while your slow neighbor 
suffers and waits, as he made the doctor 
wait, and while he is waiting the angels 
gather him in." 

The Medical and Surgical Reporter 



Care P. O. Box 843, Philadelphia. 



316-18 = 20 North Broad Street, 



TERMS : — Five Dollars a year, strictly in advance, unless otherwise specifically agreed upon. Sent three months on 
trial for $1.00. 

REMITTANCES shotdd be made payable only to the Publisher, and when in sums of Five Dollars or less, should be made 
by Postal Note, Money Order or Registered Letter, 

NOTICE TO CONTRIBUTORS :— We are always glad to receive articles of value to the profession, and when used they 
will be paid for, or reprints supplied, as the author may elect. Where reprints are desired, writers are requested to 
make a note of that fact on the first page of the MS. It is well for contributors to enclose stamps for postage, that the' 
afrticles may be returned if not found available. 

Saturday, July 15th, 1893. 



Men are gregarious. They work best 
by division of labor. Individuals differ 
in capability for achievement as in capacity 
for enjoyment. Methods and tastes are 
as varied as individuals are numerous. It 
is by aggregation that the common weal is 
best conserved, the weakness of one being 
supplemented by the strength of another 
and the benefits of superior strength or 
skill diffuse among the many. A general 
average is thus maintained which prevents 
the social organism becoming lop-sided 
or top-heavy. The resultant of many and 
diverse forces is constant and uniform 
in direction and accomplishes what would 
be impossible to the individual. Count- 
less diversities massed into a homogeneous 
power, a force irresistable by presenting 
obstacles. Association, like a smelting 
furnace, reduces to shining metal the 
gross crude ore alike with delicately- 
wrought filagree works of art. 

For mutual encouragement, for mutual 
help, for the greatest good to the greatest 

number, medical associations are organized. 
Their philosophy should be preeminently 
utilitarian and Jerremy Bentham should 
be canonized as patron saint. 

The greatest good to the greatest num- 
ber is the motto most worthy to be en- 
graved upon their official seals. 

Bacon says, "reading makes a full 
man, writing an exact man, and speaking 
a ready man." To read in order that one 
may observe intelligently, write accurately 
and speak readily and exactly is a most 
laudable ambition. But without personal 
association there is no audience to whom 
to address what has been written, and no 
intelligent ears to receive ideas when 
spoken. Discussion brushes away cloudy 
ideas, crystalizes nebulous hypotheses, 
sharpens the wit, gives command of a 
vocabulary, makes comprehension easy, 
and compels close study and advised 
speaking. One will carefully scan facts 
and their relations if they are to pass 
through the flame of criticism and will 

July 15, 1893. 



make knowledge his own before subjecting 
it to the keen scrutiny and ready and 
sharp criticism of assembled fellows who 
accept nothing as gold because of its 

Ideas beget ideas, as steel strikes fire 
from flint. The very discussion of the 
subject insures its closer study ; thus self- 
improvement carries with it an extension 
of benefit to all who appear within the 
charmed circle. The assembling of large 
bodies of men interested in the same sub- 
jects and pursuing similar lineB of thought 
kindle enthusiasm, arouses ambition, 
stimulates investigation, and often fixes 
the attention on interesting parts of the 
work which had hitherto been overlooked 
in the eager pursuit of other parts. Per- 
sonal association broadens the mind, ele- 
vates the thought, and developes love for 
the less sordid aspect of daily professional 
tasks. To the conscientious practitioner 
the annual society meeting takes him 
from the labor and anxieties of his 
round of toil, gives a much needed 
variation to his life, and affords rest and 
recreation. At the same time it bright- 
ens up his armor by the attrition of friend- 
ly minds one upon the another. He goes 
back to duty refreshed and replenished, 
and made stronger in every sense of that 

Our object then in the organization of 
a medical society should be the pursuit of 
knowledge, the development of mind, the 
strengthening of purpose, the evolution 
of truth and the general elevation of the 
standards of professional honor and pro- 
fessional acquirements. In doing these 
things a certain mutual touch of mind 
and a communion of spirit beget broader 
views and inspire more enthusiastic inves- 
tigation, the glamour of philanthopy may 
crown the dryest of facts, and the proph- 
et's vision vie with the poet's dream in con- 
necting the commonest acheivements of 
the present into the immeasurable bless- 
ings of the future. 

So long as a medical society keeps before 
it only these ulterior objects, so long as it 
ignores politics and advertising, just so 
long is it a great boon to the rank and file 
of the profession. Let work, and work 
only, year by year, draw the members to- 
gether and power for good will increase 
as time rolls by; but the very moment men 
forget these ends and begin to organize 
small cliques for office and advertisement, a 
great black mark is placed across the fairest 
escutcheon and men begin to spend time 
in laying pipe and working for votes and 
influence. Bitterness and strife and back- 
biting appear and the hard working and 
simple member to whom such things are 
disgusting drops out and looks elsewhere 
for the mental pabulum ' that he is dis- 
appointed in finding. Let the offices and 
all such emoluments be conferred upon 
the very old men who can fill a chair 
gracefully and fairly though they may no 
longer be desirous of taking part in the 
laborious work of writing papers and 
leading the discussions. The position of 
president or presiding officer is but an 
empty honor and ought to be the reward 
of long service if it is valued as a reward. 
Young men should be content to lead the 
battle against disease. If Nestor is 
present, let him preside, Achilles and 
Ulysses can fight and talk. Age in the 
chair commands and deserves respect, 
while on the floor age may not always be 
synonymous with wisdom. 


A comLinittee of the Therapeutical Society 
of Paris reported favorably on the use of the 
urethral bougie of M. Weber in incipient 
gonorrhoea. This bougie is prepared as fol- 

T>. Gum arable in powder 15 pts. 

jp^y Ivactose 5 pts. 

Glycerine i pt. 

Iodoform 2 to 4 pts. 

M. Make ten bougies 13 cm. long. 

Bougies thus prepared are soft and supple. 
They should be introduced at night, on re- 
tiring. They melt in the urethra, and are 
expelled without effort in urinating. — Med. 



Editorial. Vol. Ixix 


[Advance Sheets of the Transactions of the Medical 
Society of the State of Pennsylvania.] 

The Legislative Committee respectfully 
reports that it has at last been able to se- 
cure the passage of an efficient medical 
act by the Senate and House of Represen- 
tatives of Pennsylvania. 

By the provisions of this law, which 
still awaits the approval of the G-overnor, 
no one can enter upon the practice of 
medicine in this State after March 1,1894, 
unless he or she has a competent common 
school education, has received a medical 
diploma, and has been granted a license to 
practice medicine and surgery by the Med- 
ical Council of Pennsylvania, after an ex- 
amination by a State Board of Medical 

Applicants for license, who have re- 
ceived their medical degrees after July 1, 
1894, are not eligible for examination and 
license unless they have attended three 
courses of medical lectures in three differ- 
ent years ; and those who have received 
their medical degrees after July 1, 1895, 
are not admitted to examination for license 
unless they have studied medicine for a 
period of four years, three of which must 
have been in college. 

The Committee believes that few,if any. 
States of the Union have laws which will 
protect the public from medical incompe- 
tence more efficiently than this enactment 
of the Pennsylvania Legislature; and it 
therefore congratulates the public and the 
profession on the successful outcome of 
the work undertaken nine years ago by 
this Society. 

A short history of the efforts of the So- 
ciety may here be of interest. 

At the meeting held in Philadelphia 
May, 1884, various resolutions were offered 
by Dr. L. M. G-ates, of Scranton, Dr. Ed- 
ward Jackson, then of West Chester, now 
of Philadelphia, and Dr. John B. Roberts, 
of Philadelphia, having for their purpose 
a separation of the teaching of medical 
students from the examination and licens- 
ing of intending practitioners of medicine. 

During the fall and winter of the same 
year, committees of the Philadelphia 
County Medical Society and of the Medi- 
cal Jurisprudence Society of Philadelphia, 
in conjunction, formulated a bill estab- 
lishing a State Board of Medical Examin- 

ers and Licensers, which was presented to 
the Legislature for enactment at the ses- 
sion of 1885. A copy of this bill was 
subsequently presented by Dr. Roberts, 
for the consideration of the Section on 
State Medicine of the American Medical 
Association, at the New Orleans meeting 
in the spring of 1885, and was referred by 
that section to the general meeting of the 
Association. The Association thereupon 
passed a resolution advocating the estab- 
lishment in every state and territory of a 
State Board of Medical Examiners and 
Licensers, directed the Permanent Secre- 
tary to transmit a copy of the proposed 
law to each state society, and requested 
each state society to report upon the sub- 
ject to the Association in 1886. 

In consequence of this action of the 
American Medical Association, the Medi- 
cal Society of the State of Pennsylvania 
had before it for discussion at the Scran- 
ton meeting in 1885, not only the report 
of its committee on the "^ Best Method of 
G-ranting the License to Practice Medi- 
cine,^' but also a completely drafted bill. 
Much attention was, therefore given to 
the subject, and a committee was author- 
ized to prepare a bill for presentation to 
the Pennsylvania Legislature. At the 
Williamsport meeting in June, 1886, the 
committee reported a bill modeled to some 
extent on that proposed and advocated by 
the Medical Jurisprudence Society of 
Philadelphia, which had been sent to the 
Society by the American Medical Associa- 
tion as above detailed. The original bill 
had been introduced in the Legislature of 
1885, as has been mentioned, but had 
failed to become a law. 

Since this action successive committees 
of the Society have been earnestly en- 
gaged in organizing the profession, for 
the purpose of educating the public as to 
the necessity of medical legislation to 
protect the citizen from medical igno- 
rance; and bills have been introduced at 
each session of the Legislature only to 
meet with successive defeat. 

The present committee was authorized 
to have the bill, adopted by the Society at 
the Harrisburg meeting of last year, 
introduced in the Legislature convening 
January 1st of this year (1893). It ac- 
cordingly had the bill introduced in the 

July 15, 1893. 



House of Eepresentatives by Hon. Henry 
K. Boyer, and in the Senate by Hon. 
Charles A. Porter. The committee, in 
addition, published and distributed a 
twenty-eight page pamphlet, showing the 
constitutionality of such legislation, the 
need of a law in this State, and the 
favorable view of the bill held by many 
representative physicians, who, from all 
sections of Pennsylvania, furnished the 
committee with written approvals. In 
this pamphlet were also published reso- 
lutions unqualifiedly endorsing the bill 
passed by the faculties of the Jefferson 
Medical College, the University of Penn- 
aylvania, the Woman's Medical College of 
Pennsylvania, and the Philadelphia Poly- 

When the bill had been before the 
Legislature for two and a half months, it 
became evident to the committee that its 
earnest and unremitting efforts would be 
unavailing, and that the bill as then 
drafted could not be enacted into law. 
The passage of the bill as introduced was 
vehemently opposed by the sectarian 
physician of the State and by certain 
gentlemen belonging to medical schools 
and county medical societies in affiliation 
with this Society. Although your com- 
mittee might have been able to have 
secured the passage of your bill against 
the wishes of one of these forces, it could 
not accomplish the work against such a 
combination of antagonistic agencies. 

On March 19th, 1893, therefore, the 
committee held a conference meeting with 
prominent officers of the Society and re- 
presentative members of the faculties of 
the University of Pennsylvania, Jefferson 
Medical College, the Woman's Medical 
College of Pennsylvania and the Philadel- 
phia Polyclinic. As a result of this con- 
ference the committee decided that to 
modify the bill in such a manner as to se- 
cure the passage of a law, similar to that 
which has been so satisfactorily operative 
in the State of New York, was wiser than 
to permit the open and hidden enemies of 
higher medical education to rejoice at hav- 
ing once more defeated the Society's efforts 
to give Pennsylvania an effective medical 
law. It was also thought that if a medical 
bill was not passed at this session of the 
Legislature, it was probable that there 
would be little chance of any such legisla- 
tion being effected for many years to 

Accordingly the bill which passed both 
houses of the Legislature last week (May 
10th) was substituted for the original bill, 
and successfully pushed to final passage. 
A copy of the law is appended to this re- 
port. Its provisions are briefly as follows: 

From March 1st, 1894, the Medical 
Council of Pennsylvania shall have control 
of the examination and licensing of all 
physicians intending to enter upon practice 
in the State. 

The Medical Council shall decide as to 
the competency of the preliminary educa- 
tion of intending practitioners and as to 
their moral character ; and must require 
them to have a medical diploma conf ering 
the full right to practice all the branches 
of medicine and surgery. Diplomas grant- 
ed to such applicants after July 1st, 1895, 
must have been obtained after four years 
medical study, three of which years must 
have been in college. 

When these facts have been satisfactori- 
ly proved by affidavit, the applicant for 
license pays a fee of twenty-five dollars and 
is referred for examination to one of the 
three State Boards of Medical Examiners, 
which substantially act as committees 
under the supervision of the Medical 

The three State Boards of Medical Exa- 
miners are appointed by the Grovernor from 
the members respectively of the Medical 
Society of the State of Pennsylvania, the 
Homoeopathic State Medical Society and 
the Eclectic State Medical Society ; and 
consist each of seven members. 

The applicant makes a choice of the 
Board by which he wishes to be examined; 
but the questions must be the same before 
the three Boards in all branches except 
materia medica, therapeutics and practice 
of medicine. The Medical Council, more- 
over, selects the questions for all examina- 
tions from lists of questions submitted to 
it by the three Boards of Examiners. The 
examinations must be in writing and the 
questions, answers and marks preserved for 

The Medical Council, having received 
notice that an applicant has passed a suc- 
cessful examination, issues its license, 
with the seal of the Commonwealth at- 
tached, to the candidate, if he be ad- 
judged by the Council to be duly qualified 
to practice medicine and surgery. 

The Council fixes the standard of qual- 
ifications, and has a veto on all rules and 



Vol. Ixix 

regulations adopted by the three Boards 
of Examiners. It may issue licenses 
without examination to physicians licensed 
hy Medical Examining Boards or Boards 
of Health of other states. 

The Medical Council consists of the 
President of the State Board of Health 
and Vital Statistics, representing the 
medical branch of the State Grovernment, 
the Attorney G-eneral, representing the 
legal department of the G-overnment, the 
Superintendent of Public Instruction, 
representing the Educational department, 
and the Lieutenant Governor and the 
Secretary of Internal Affairs, representing 
the Legislatiye and Executive depart- 
ments, and finally the Presidents of the 
three State Boards of Medical Examiners. 

The Committee, in closing this lengthy 
and perhaps tedious report, wishes to ex- 
press its heartiest thanks to Hon. Henry 
K. Boyer and Hon. Charles A. Porter, 
who introduced the Society's bill in the 
House of Kepresentatives and the Senate, 
respectively, and also to those physicians 
and other members in both Houses ; who, 
by their counsel and advocacy of the bill, 
rendered incalculable aid. In this place 
it is also proper to express its great obli- 
gation to Hon. Frank M. Eiter of the 
House of Kepresentatives and Hon. John 
B. Showalter of the Senate; who two 
years ago so actively advocated the pas- 
sage of the bill introduced by this Society. 

When the bill had very nearly reached 
the point of final passage, it was found 

that the committee's expenses would ex- 
ceed the appropriation made by the 
Society for its use. The members of the 
committee, however, concluded that they 
would bear the additional expenses per- 
sonally, rather than permit the bill to 
fail, after the Soctety had so nearly 
reached the goal for which it had been 
striving for nine years. All bills paid by 
the Society have been scrutinized by the 
Secretary of the Committee, approved by 
its Chairman, and then sent to the Publi- 
cation Committee by which orders have 
been drawn on the Treasurer as required 
by the laws of the Society. The expenses 
incurred by the Committee, in excess of 
the appropriation will be something less 
than one hundred and fifty dollars. 

Since the work assigned to the Commit- 
tee has now been practically completed, 
the Committee respectfully asks to be 

All of which is respectfully submitted. 

H. a. McCOEMICK, Chairman, 



JOHN B. EOBEETS, Secretary. 

[The law to which the above report 
refers was published in the Medical and 
SuBGiCAL Eepokter, June 3, 1893. — 



To The Editor : Dr. Eoberts' discus- 
sion of "^ The Points of Similarity between 
us and Homoeopathic Physicians " in the 
issue of the Eeporter of May 27th, is 
interesting and suggestive. The obvious 
criticism might be offered — which casts no 
reflection on the author of the excellent 
paper — that whether the statements made 
are viewed as an apology for or an eluci- 
dation of the actual practice of Homoeo- 
pathy, they might have come more ap- 
propriately from a member of the Homoeo- 
pathic school. It would seem that the 

members of a medical sect which represents 
the objection of a small minority of the 
profession to the general principles of 
therapeutics followed by the majority, 
would, ipso facts, be placed on the de- 
fensive. Until the homoeopathic school 
was organized, there was really no such 
thing as a school or sect of medicine in the 
present sense of the term. There were 
individual differences of opinion both as to 
theory and practice, there were national 
and local jealousies in the days when 
-narrow-mindedness and bigotry pervaded 

July 15, 1893. 



all ranks of society, but whatever general 
organizations of physicians existed were 
based on a common interest in a com- 
mon life work. Perphaps it is the natural 
sympathy for the " under dog " that 
occasions the popular sentiment of antag- 
onism to anything that savors of hostility 
to the ' 'new school. '^ Even those of the laity 
who are not avowedly attached to Homoeo- 
pathy wonder that physicians should expect 
from one another less of open rivalry and 
more of occurrence in opinions and methods 
than do those engaged in other professions 
and business. But for several reasons it is 
desirable that the medical profession should 
be united. The results of their work to 
the community at large are of transcendent 
importance, since health and life, instead 
of wealth and convenience are at stake. 
Financial errors may be rectified, imperfect 
handicraft corrected or restitution made, 
wrong legal opinions revised and decisions 
appealed, but, on the part of the physician 
and surgeon, a mistake, or a failure to 
adopt the best possible method is seldom 
without evil result and is usually irrevoca- 
ble. Again, while a merchant can en- 
trust almost everything, except the general 
supervision of his affairs, to subordinates 
whom he can hire for six to fifteen dollars 
a week and can feel satisfied if his business 
is carried on with financial honesty and 
success, the physician's money- making 
though important, is nevertheless, trivial in 
comparison with the labor of scientific 
study and careful practice. Every detail 
of his strictly professional duties must 
receive his personal attention and must be 
done accurately. He is continually con- 
fronted in his patients with problems which 
require a familiarity with chemistry, 
physiology, anatomy, psychology, bac- 
teriology, microscopy, pathology, medical 
jurisprudence and other branches of 
study and a practical experience which no 
one man unaided can acquire. Physicians 
therefore, more than any other body of 
men are interdependent and grow to feel 
that every doctor who is not with them is 
against them. 

The laity are inclined to draw com- 
parisons between schools of medicine and 
religious sects. The analogy holds good 
to the extent that the homcieopathic 
school was a splitting off of a small body 
from an originally undivided profession, 
but there are the marked differences that 
in medicine there never has been fixed 

creeds except those adopted by dissenting 
sects, nor has the regular school been 
bound to any foimalism other than the 
code of ethics, which is simply an ap- 
plication of the Golden Rule and general 
principles of honor to special cases, and 
to which, as Dr. Roberts observes, no 
serious objection is offered by Homoeo- 
paths. Moreover, a man's goodness or 
badness, religiously speaking, depends not 
so much on the correctness of his dogmas 
as upon his intentions, while medical 
practice is good or bad according to 
whether the ideas which it follows are 
right or wrong. 

A closer comparison can be made to the 
legal profession, in which, at present, the 
term school (in the sense of sect) is 
utterly meaningless. If, however, at 
some future time a number of lawyers 
should organize into a sect opposing the 
common construction of law and the 
customary practice of the majority of the 
profession, their attitude would be ana- 
logous to that originally assumed by the 
disciples of Hahnemann, and it would be 
simply a question of numbers and in- 
fluence whether they would be considered 
a coterie of visionaries or whether they 
would succeed in splitting up the legal 
profession into schools. 

It is not now appropriate to enter into 
a discussion of the merits or demerits of 
Homoeopathy. A great point will be 
gained if the laity can be taught to regard 
medical sectarianism as intrinsically evil, 
to be justified only by strong dissenting 
convictions. If they can be made to 
appreciate that it is something more than 
dollars and cents that actuates the demand 
of the regular profession for a concentra- 
tion of medical effort and thought, we 
shall, at least, not be condemned for de- 
clining to extend the right hand of fellow- 
ship to sectarians. If the tenets of 
Homoeopathy can be plainly presented to 
the laity, if Homoeopath ists can be driven 
from their attitude as martyrs to the 
cause of mild doses and medical renova- 
tion, and pinDed down to a defense or re- 
nunciation of Hahnemann's teachings, 
then we can trust the common sense of 
our non-medical fellow citizens to choose 
wisely, in the main, between regular 
medicine on the one hand and sectarian- 
ism on the other. 

Dr. Roberts has confirmed by abundant 
testimony the growing sentiment that the 



Vol. Ixix 

homoeopathy of to- day has practically cut 
loose from the restrictions of Hahnemann, 
and that it is to a great extent parasitic 
upon the medical teaching and literature 
of the regular profession. Far from being 
creditable to homoeopathy, these facts 
carry with them the odium which must 
always attach to any individual or society 
whose avowed principles and proctices are 
at variance. This is a period when reli- 
gious denominations are revising their 
creeds and eliminating inconsistencies be- 
tween nominal and actual beliefs. Let the 
homoeopathic medical profession institute 
a general and formal inquiry as to what 
its tenets really are, and let it then pro- 
claim them publicly in such plain terms as 
to obviate any future misunderstanding. 
My personal opinion is that such a general 
sifting of the homoeopathic school would 
divide it into four parts. First, a few 
surviving believers in the original high- 
attenuation homoeopathy would be found ; 
secondly, there would be a larger percent- 
age of honest adherents to a modified ho- 
moeopathy, men whom we may esteem as 
friends and as citizens, but whose medical 
practice would be unqualifiedly different 
from our own; thirdly, there would be a 
goodly number of men who are unfortu- 
nately prevented from being one with us 
by the difficulties in the way of gaining 
membership in formally-organized bodies 
of regular physicians, or by an attachment 
to early associations, but who are homoeo- 
paths only in name, and who regret the 
inconsistent attitude in which they have 
placed themselves; lastly, there would be 
the chaff of the winnowing, a consider- 
able, though not large, proportion of men 
and women who call themselves homoeo- 
paths to secure a share of an established 
practice, or because they think that the 
mental association of homoeopathy with 
small and pleasant doses will prove profit- 
able. These are creatures who are homoe- 
opaths for what the name is worth, and 
who would be eclectics, vitopaths or mag- 
netic healers, if the financial outlook was 
better in any of these directions. 

I agree most heartily with Dr. Eoberts, 
that all obstacles should be removed from 
the way of these men, who, without secta- 
rian beliefs, find themselves in sectarian 
societies and wish to unite with the regu- 
lar profession; but it does not seem to me 
that the accidental wandering of homoeo- 
paths from homoepathic standards brings 

them into harmony with the organization 
which they still antagonize under the 
falsely applied name of allopathy. 

A. L. Benedict. 
174 Franklin st., Buffalo, June 30, '93. 

Editoe Medical and Surgery Ee- 
PORTER : Dear Sir : — There is a little 
point in Anaesthesia that I have never seen 
mentioned in any communciation on the 
subject, and yet is of such importance 
that it might not be amiss to call atten- 
tion to it in a brief paragraph. 

In many cases of anaesthesia at any stage 
there may occur long, deep sighing respir- 
ation. This may take place, and frequent- 
ly does, immediately after an attack of 
vomiting or after slight evidence of return 
to consciousness, though it is just as apt 
if not more so, to occur during deep anaes- 
thesia. It is not evidence of returning 
consciousness, but is exactly similar to or 
the same as that which takes place during 
or after periods of intense concentration 
during the waking period, as is commonly 
seen in churches, theatres, etc. It is an 
unconscious effort to inhale more air, and 
shows a defective or careless respiration. 
My only object in calling attention to this 
phenomenon is to advise all anaesthetizers 
to do what I have seen very few of them 
do. Eemove the inhaler instantly and 
allow nature that which she is endeavoring 
to get. 

This is where the disadvantage of an im- 
movable apparatus comes in. It is pos- 
sible that the amount of anaesthetic which 
may be drawn in from a saturated inhaler 
by one of these deep sighing respirations, 
during deep anaesthesia, might be just 
sufficient to carry the patient over the line. 
I would like also to give in my evidence 
against the custom of largely increasing 
the amount of vapor daring and after 
attacks of vomiting with the idea of con- 
trolling the vomiting, especially is this 
dangerous in the later stages of the anaes- 
thesia, or operation. 

Yours very truly, 

Wm. H. Burr, 
216 W. 9th St., Wilmington, Del. 

If some men would get nearer to the 
Lord, they wouldn't have to make so 
much noise in church. 

Don't try to carry all your religion in 
your head. 

July 15, 1893. 




In a recent address before the New York 
Academy of Medicine (Medical Record), 
Dr. Weir Mitchell gives the following di- 
rections for the use of this agent by per- 
sons needing the modified rest-cure : 

" What I dread most at the start, in all 
cases for rest, is grave insomnia. Whether 
it be accompanied by a state of mild men- 
tal excitement such as we all know, or is a 
pure incapacity to go to sleep or to stay 
asleep, or whether it be in popular medical 
belief a congested state, I am apt at once 
in bad cases to use twice a day lithium 
bromide, at first in thirty-grain doses, at 
noon, at 6 and 9 P. M., given in the malt 
or not, and soon decrease grain by grain. 
If I want a positive aid at bedtime, I pre- 
fer sulfonal in hot water. But of greater 
value are some of the hydro-therapeutic 
devices — and best of these is what is 
known, or not known, as the * drip sheet.' 
Just how this is to be given is of the ut- 
most importance. The following memo- 
randa must answer to show how careful 
one must be in my opinion, as to these 
details. I give it here, in brief, much as 
I do to the patient not under the immedi- 
ate care of a nurse. I cannot help add- 
ing that several of the most useful of the 
water processes are neither taught in our 
schools, nor so accurately in hydro-thera- 
peutic text-books as to be of much value 
to the general practitioner. 

Memoranda for Use at Bedtime of Drip 
Sheet. — Basin of water at 65° F. Lower 
the temperature day by day, by degrees, to 
bb° F, or to still less. Put in the basin a 
sheet, letting the corners hang out, to be 
taken hold of. The patient stands in one 
garment in comfortably hot water. Have 
ready a large, soft towel and iced water. 
Dip the towel in this, wring it, and put it 
turbanwise about the head and back of the 
neck. Take off night-dress. Standing 
in front of patient, the basin and sheet 
behind, the maid seizes the wet sheet by 
two corners and throws it around the pa- 
tient, who holds it at the neck. A rough, 
smart, rapid rub from the outside applies 
the sheet everywhere. This takes but two 
minutes or less. Drop the sheet, let the 
patient lie down on a lounge upon a blan- 
ket, wrap her in it. Dry thoroughly and 

roughly with coarse towels placed at hand- 
Wrap in a dry blanket. Remove ice-wrap, 
dry hair, put on night-dress. Bed, the 
feet covered with a flannel wrap. 

If all this seems to you, as you read it, 
too absurdly minute, I shall feel some re- 
gret. Yet believe me, it is worth the trou- 
ble, and the drip-sheet is a remedy past 
praise. If it fail, a pack may succeed; 
but this is more familiar to you. I doubt 
if the use of the drip-sheet is as well 

The IiTDiCATiONS for the Ei^uclea- 
Tioif OF AN Eye are thus summarized by 
Jackson (Philadelphia Polyclinic) : 

1. The presence' in the eye of a malig- 
nant new growth, as glioma, sarcoma, or 
tuberculosis. This indication is impera- 
tive, no matter how much vision the eye 

2. The presence in the eye of a foreign 
body, with iridocyclitis. If the injury be 
recent and the inflammatory process still 
active, and the patient cannot remain un- 
der observation, an eye with anything less 
than thoroughly useful vission should be 

3. The presence of a foreign body in a 
blind eye. 

4. Blindness with diminished tension 
of the eyeball, following perforation eith- 
er from traumatism or corneal ulcer; 
most urgent after traumatic perforation of 
the exposed portion of the sclera. 

5. Blindness from irido- choroiditis 
without perforation of the eyeball, if the 
patient cannot remain under observa- 

6. Sympathetic inflammation, provided 
the exciting eye does not possess vision suf- 
ficiently good to be weighed against the 
chances of the sympathizing eye. 

7. The actual presence of sympathetic 
irritation; not the risk of it, unless the 
patient is likely to be out of reach of sur- 
gical aid. 

8. Persistent pain in a blind eye, suf- 
ficient to annoy its possessor or tempt him 
to the use of analgesic drugs. 

9. Serious disfigurement of a blind eye, 
even if free from pain or risk of causing 
sympathetic disease. 


Current Literature. 

Vol. Ixix 



for June. 

Dr. Thomas H. Manley reports a 

Fibro=Myoma of the Uterus and Broad 
Ligament of Forty =five Years' Duration. 

The woman lived to be 76 years old. The 
tumor had been examined by numerous phy- 
sicians, few of whom agreed on a diagnosis, 
the opinions ranging between ovarian tumor 
a,nd hypertrophic fibrosis of the right lobe of 
the liver. At one time she was under the 
care of Dr. Gunning Bedford, and was very 
■desirous of having an operation performed 
for relief ; but, owing to his influence, it was 
not done. The case demonstrates that, under 
certain circumstances, the presence of a uter- 
ine fibroid is not incompatible with longev- 
ity. In the end, though greatly reduced in 
volume, yet it still persisted as a foreign body, 
was an inconvenience to her while she was on 
iter feet, and was a constant menace to her 
•comfort while in bed. At the post mortem it 
was noticed that no trace of the uterus re- 
mained, nor anything like a normal ovary. 
The abdominal muscles had atrophied as the 
result of the continued pressure. In his re- 
marks on the treatment of uterine fibroids, 
the author says that nothing in the way ot 
direct surgical treatment should be recom- 
mended till we have first given constitutional 
and local measures a fair trial. He thinks 
that electricity possesses useful properties, but 
denies that it will dissolve and scatter away 
a calloused old fibroid. The electro-puncture 
should be interdicted. When the cervical 
canal is short and the tumor low down in the 
pelvis, the cervix can be dilated and the tu- 
mor removed en masse or piecemeal. Espe- 
cially may this be done in the case of submu- 
cous or intra-uterine tumors. The author 
thinks it a mistake to teach that metrorrha- 
gia is never absent in cases of fibroid tumors, 
as he has seen cases in which the patient 
never had any hemorrhage. Hysterectomies 
for fibroids are justifiable when they have de- 
stroyed the uterus, particularly with those of 
advanced years. Abdominal hysterectomy 
is a highly valuable operation in skilled 
hands and under proper surroundings. 

Dr. W. F. Metcalf presents "A Report of 
Two Cases of Marginal Eczema," in which 
local treatment was of no avail till after the 
sexual organs had been put in good condi- 
tion. In one case an ovarian growth was 
removed, in the other a lacerated perineum 
was repaired. 

Dr. C. G. Jennings contributes a paper on 

The Induction of Labor in the Albuminu^ 
ria of Pregnancy. 

His experience leads him to look uj^on al- 
buminuria as a very grave complication of 
pregnancy ; one demanding from the physi- 
cian the utmost care and the best judgment 
to bring to a favorable issue. Termination in 
the complete disappearance of the albumin- 
uria before the end of pregnancy is, in his 

opinion, unusual. While the statements of 
many writers show that women frequently go 
to term and through labor without disaster, 
to permit her to run the risks to both herself 
and child of acute renal insufficiency seems 
rarely justifiable. In mild albuminuria before 
the seventh month, the case should be put 
upon proper medical treatment and carefully 
watched. If the conditions improve or re- 
main stationary, interference may be delayed 
until it is certain that the child stands a good 
chance of living, well on in the seventh 
month. In severe albuminuria before the 
seventh month, with marked renal insuffi- 
ciency and dropsy, labor should be induced 
as soon as it is seen that medical measures 
have little or no beneficial influence. These 
cases probably always terminate in spontane- 
ous premature delivery,with the death of the 
child or convulsions. In albuminuria occur- 
ring after the seventh month, labor should be 
induced if the condition remain stationary 
after a week or two of proper medical treat- 
ment. Daily examinations of the urine 
should be made, and any marked increase in 
the albumen or a decided decrease in the 
urine solids should be followed by prompt in- 
terference. In severe cases seen for the flrst 
time during the seventh or eighth month, 
and showing a decided decrease of urine sol- 
ids and much dropsy, artificial labor should 
be promptly induced. 

Dr. R. B. Maury reports " A Case of Ovari- 
an Pregnancy." The specimen was referred 
to Dr. Alan J. Smith for an opinion, and he 
reported it an undoubted case of true ovarian 

Dr. B. E. Hadra presents "A Contribution 
to the Pathology of the Fourchette." Dr. A. 
W. Hitt discusses "The Proper Treatment of 
Laceration of the Cervix." The remaining 
paper is by Dr. Joseph Price, entitled, " Gy- 
necology and the General Practitioner," and 
has been published in The Medical and 
Surgical Reporter for May 13, 1893, page 


for July. Dr. F. Forchheimer contributes a 
paper on 

The Intestinal Origin of Chlorosis. 

The author concludes, as the result of experi- 
ments upon animals, that the number of red 
corpuscles is diminished in the veins of the 
intestine, while the quantity of haemoglobin 
remains the same; therefore, haemoglobin is 
absolutely increased in the vein and each 
red corpuscle carries more haemoglobin in 
the vein than in the artery. P rom this ob- 
servation the conclusion can be drawn that, 
in the rabbit, haemoglobin is taken up by the 
blood from the intestine, and that it must i be 
formed either in the parts supplied by the 
arteries — i. e., the mucous membrane in its 
broadest sense — or within the intestinal 

July 15, 1893. 

Current Literature. 


canal. The author states in conclusion, that 
possibly some other origin for haemoglobin 
naay exist than in the intestine; from all 
evidences, however this is the principal source 
and in chlorosis the most important. He 
presents the results of the treatment by salol 
or hydro-naphthol (so called). No iron was 
used. The object of the treatment was to 
prevent abnormal decomposition in the in- 
testine. The number of cases is too small to 
draw any conclusions from but the results 
were good. 

Drs. Theodore Diller and J. J. Buchanan 

A Case of 5ub*corticaI Cyst of the Lower 
Part of the Left Ascending Parietal Con- 

The case confirms, as much as a single case 
can, the generally accepted ideas concerning 
the localization of certain motor functions in 
the Rolandic region. It lends support to the 
opinion (upon which there is not so much 
unanimity) that there is no cortical represen- 
tation of sensation in the pre-central convo- 
lution, and also offers distinct negative evi- 
dence in support of the view that this convo- 
lution is not related to the function of mus- 
cular sense. The hypothesis of Seguin, Mills 
and others, that when hemiparesis precedes 
spasm the lesion is sub-cortical is confirmed 
by the evidence presented by the case. From 
the surgical aspect of the case, the admirable 
control of hemorrhage during the operation 
by means of a rubber band around the head 
is worthy of mention. The operation, which 
was performed by Dr. Buchanan, proved 
successful as far as recovery from the surgi- 
cal procedure is concerned. The spasms 
still continue but are lessened in number. 

Dr. B. Farquhar Curtis contributes a paper 

Cases of Bone Implantation and Transplant 
tation for Cyst of Tibia, Osteomyelitic 
Cavities, and Ununited Fractures. 

After reviewing the different methods and 
materials used for the purpose, the author 
concludes that Senn's decalcified bone ap- 
pears for the present to be the most practical 
material for use in ordinary cases, while we 
are waiting for the ideal of the future— the 
insertion'of a piece of living bone that will 
exactly fill the gap and will continue to live 
without absorption. The author reports four 
cases successfully treated by bone implanta- 
tion. The most rigid antisepsis is necessary 
in the operation and the author cautions 
against the too free use of iodoform on ac- 
count of the dangers of poisoning from it. 
Such an accident has not happened to him 
but the author thinks the caution necessary. 
Dr. Judson Daland discusses 

The Treatment of Cholera by Hypoder= 
moclysis and Enteroclysis. 

The treatment is principally of value in the 
evacuant or collapse stage of the disease. 
The solution used for hypodermoclysis con- 
sists of two small teaspoonsful of sodium 
chloride to a quart of hot water, which has 
been distilled and sterilized. The operation 
is one of great simplicity, requiring only a 
small-sized aspirating-needle and canula 

which is attached to the rubber tube of an 
ordinary fountain syringe. The best point 
for the introduction of the needle is in either 
flank, between the ribs and the crest of the 
ilium; the inner surface of the thighs may 
also be used. Observation has shown that 
there is danger in the injection of fluids in 
beneath the skin of the neck, as two cases of 
fatal oedema of the larynx following the 
operation have been reported. The operation 
should be performed under strict antisepsis. 
The first injection for an adult should be one 
or two quarts, and the solution should have 
a tenaperature of 110°F. at the reservoir which 
will be reduced to 105° F. after traversing 
the long tube to the subcutaneous space. 
The objection to enteroclysis that the injec- 
tion will not pass the ileo-csecal valve, the 
author believes to be without foundation. 
He reports that several patients to whom in- 
jections of tannic acid were given, vomited 
tannic acid, thus proving that the fluid 
passed the valve. The liquid for enteroclysis 
should also have a temperature of 110° F. 
which will be reduced about five degrees by 
its passage through the tube. Besides set- 
ting forth the value of the above procedures, 
the paper also deals with the general treat- 
ment of cholera. 

Puerperallnfection considered from a Bacterid 
ological Point of View, wilh Special Refer= 
ence to the Question of Auto=lnfection 

is the title of a paper contributed by Dr. J. 
Whitridge Williams. 'After exhaustively 
reviewing the opinions of the observers of 
this subject, the author concludes that the 
general practitioner will do best for himself 
and his patient if he acts as if there were no 
such thing as auto-infection, and does not 
attempt to deal with any organisms which, 
may exist in the vagina, aud contents him- 
self with the most scrupulous cleanliness on 
his part and careful disinfection of the exter- 
nal genitals. The author also believes that it 
is impossible to disinfect the vagina with the 
means ordinarily at hand, and with the pa- 
tient in her bed. This of course does not 
apply to well regulated hospitals, for there 
the douche may be given with greater anti- 
septic precautions. The best results will be 
obtained when, in addition to the most rigid 
subjective antisepsis, we consider each case 
separately, and make a preliminary micro- 
scopic examination of the vaginal secretion. 
If the secretion be normal there can be no 
possible justification for the use of the 
douche, but if pathological there may be. 

Dr. Heneage Gibbes contributes a paper on 
" The Parasitic Nature of Cancer " in which 
he says that the most careful examination of 
specimens, hardened after a method which 
gave normal appearances in sections of nor- 
mal liver, failed to show anything that could 
be construed into any form of parasite. 

The remaining papers in this issue are: "A 
Suggested Improvement in the Correction of 
Lenses for Photomicrography, Photography, 
and Photastrography " by Dr. Henry G. 
PiflTard, and "Simple Idiopathic Muscular 
Atrophy, beginning in the Flexors of the Hips 
— Buzzard's Form" by Dr. Howell T. 



Vol. Mx 


Differential Diagnosis of the Various 

Forms of Convulsions in Young Chil= 


Dr. Landon Carter Gray in discussing this 
subject before the New York Academy of 
Medicine, said that it involved the consider- 
ation of a large number of diseases, for a con- 
vulsion is a symptom, and not in itself a dis- 
ease. A broad general classification of con- 
vulsions might be made into organic and 
functional. We know very little of cerebellar 
disease in the child, and our attention must 
be directed entirely to the cerebrum. In the 
organic class are the convulsions due to men- 
ingitis, encephalitis, meningo-encephalitis, 
and hydrocephalus. An organic lesion may 
be suspected when there is paralysis of some 
function of the cerebrum, as of sight or hear- 
ing. Cerebral hemorrhage may alone cause 
convulsions, and may be local or widespread. 
Organic lesions in the brain may cause con- 
vulsions, and may also impair mental power. 
Recently much has been said regarding the 
possibility of mental disturbance due to pre- 
mature ossification of the bones of the skull. 
Lannelongue's operation has become a fad. 
It is useless, however, where there is distinct 
evidence of an organic lesion, as paralysis, 
blindness, or deafness. It can be of value 
only when the mental power alone is re- 

A most interesting subject is that of func- 
tional convulsions. Chorea is 
mistaken for disorders of convulsive nature. 
Chorea appears under two forms. In the one 
the movements are fibrillary and very quick 
in their occurrence and beyond the control 
of the patient; in the other the motions are 
more gradual and wormlike. Experiments 
have recently been made regarding the con- 
vulsions due to digestive disturbance. It 
has been found that the normal putrefaction 
which always occurs during digestion some- 
times becomes abnormal or irritative. In 
these cases the patient is slightly dyspeptic, 
and indican may be detected in the urine. 
These investigations are interesting and im- 
portant, as they throw light upon facts 
which have long been known regarding the 
close association of digestive disorders and 
convulsions. Peripheral irritation has long 
been considered a cause of convulsions. 
There is no positive proof that ovarian disease 
ever of itself causes convulsions. Removal 
of the disorder is rarely followed by more 
than temporary relief. True epilepsy is 
masked by paroxysms which occur in series. 
This fact must be considered in discussing 
the disease, and in drawing conclusions re- 
garding the treatment. No one can say at 
what period epilepsy is cured. The convul- 
sions sometimes appear months or even 
years after a cure has apparently been ef- 
fected. — Med. Review. 

Etiology of Whooping=Cough. 

Dr. Ritter, of Berlin, has been making 
some researches into this subject. When it 
was possible to obtain any expectoration at 
the end of a paroxysm of coughing, the spu- 
tum was received into a sterilized vessel and 
carefully washed with distilled water. Small, 
opaque particles were generally found, and 
these were removed with due precautions 
and cultivated on agar-agar. Small colonies 
appeared within twenty-four hours. Under 
the microscope these were found to consist of 
diplococci. The colonies were opalescent and 
grayish in color, and adhered firmly to the 
surface of the cultivating medium. These 
diplococci are different from those described 
by Fraenkel as present in pneumonia. Al- 
though his experiments on animals were not 
yet conapleted at the time the report was 
made to the Berlin Medical Society, yet Dr. 
Ritter had already obtained results which 
seemed to point to this micro-organism as the 
specific agent in the production of pertussis. 
—N. Y. Med. Becord. 


Surgery of the Gall = Bladder. 

An excellent resume by Pick of Czerny's 
publication on the present status of this 
branch of surgical work merits attention. 
Czerny bases his conclusions on eighteen 
cases. He considers that cases without dis- 
comfort, even if the gall-bladder can be felt 
distended with calculi, should not be inter- 
fered with surgically. In these cases there 
may be short attacks of colic with jaundice ; 
but they are readily relieved by medicinal 
treatment, and are not of frequent occurrence. 
The surgical cases are when the symptoms 
are severe, the attacks frequent, and the 
patient is not free from pain or discomfort 
during the remissions. The operative cases 
are classed either as those without long-con- 
tinued icterus or with continued icterus. 
The cases w^ithout icterus often are difficult 
of diagnosis. Extirpation of the gall-bladder 
is not considered a desirable operation, since 
it does not prevent the recurrence of calculi 
in the dilated hepatic ducts ; also, since the 
gall-bladder is valuable in forming a new out- 
let for the bihary current by its union (chole- 
cysto-enterostomy) to the duodenum in cases 
when the common duct is occluded. In the 
non-icteric cases the surgeon has to deal 
mostly with the gall-bladder alone, since the 
ducts, except the cystic, are patent. The 
method of operating in two sittings is in- 
dicated when the contents of the bladder is 
purulent. The method used where the im- 
mediate incision is made is to pack the gall- 
bladder in iodoform gauze so as to shut off the 
abdominal cavity ; then incise, and wash out 
with a boric-acid solution. The advantage of 
the open abdominal wound is that the 

July 15, 1893. 



exterior and adjacent organs can be examined . 
When the bladder is opened after adhesions 
have formed, the interior of the bladder only 
is accessible, and the rest has to be left to 

An attempt at suture of the bladder wound 
and its replacement in the abdomen should 
never be done except when the bladder is in 
a normal condition. 

In cases of suppuration or stenosis of the 
cystic duct the formation of a temporary 
fistula is recommended. 

The typical operation for calculi is incision 
evacuation of calculi, suture of the gall- 
bladder, abdominal drainage for a short time. 
Extirpation is only indicated in severe or 
carcinonaatou s degeneration . W hen the com- 
mon duct is occluded, operate as long as the 
patient's condition will permit. If the ob- 
struction (stone or flexions) cannot be removed 
cholecysto-enterostomy is recommended. 
The incision recommended is a right-angular 
one, the vertical short arm in the linea alba. 
The horizontal arm immediately belaw the 
umbilicus and extending to the right. This, 
Czerny thinks, gives the best opportunity to 
investigate the ducts as well as the gall- 

The risk to life is now less than for opera- 
tions on the urinary bladder. — Ann. of 


Danger of Vaginal Pessaries. 

Dr. Neugebauer, of Warsaw, has published 
an exhaustive analytical monograph on this 
question, so inaportant in these days when 
gynecology is widely practiced by the surgeon 
and physician as well as the specialist. Two 
hundred and forty-two cases of injury have 
been collected and analyzed, five more being 
added in an appendix. Tabulating the 
results, Dr. Neugebauer presents the medical 
public with the folio wingjformidable statistical 
records : Twenty-three cases of perforation of 
rectum alone by the pessary ; twenty cases 
of perforation of the bladder alone ; ten cases 
of perforation of the bladder and rectum ; one 
case of ureteric fistula alone; one case of ureteric 
and vesico-vaginal fistula ; one caseof urethral- 
vaginal fistual ; two cases of perforation of 
Douglas' pouch (neither fatal) ; three cases of 
perforation of the vaginal walls, the extruded 
portion of the pessary lying in the pelvic 
connective tissue ; and six cases of entry of a 
vaginal pessary into the uterus. 

As to the age, one patient was ninety years 
old ; she had worn a wooden pessary forty- 
five years. The youngest was nineteen. 
The time during which the pessary was worn 
(and often forgotten) is tabulated, the non- 
agenarian just mentioned heading the list ; 
two other women wore their pessaries for 
forty years ; and twenty, besides these three, 
wore the instrument over twenty years. The 
toleration of the vagina is very varied in dif- 
ferent individuals, even for the same kind of 
pessary ; thus in some cases the pessary 
became fixed, and tended to ulcerate into 
the vaginal walls within two or three 

months, whilst in others the appliance 
was worn over twenty years without causing 
any objective or subjective troubles. How 
fetor could have been absent in these tolerant 
cases it is hard to understand. We must 
remember that the same kind of pessary is 
not always introduced with the same skill, 
whilst other pessaries may be bad in principle 
or ill-made by the manufacturer, and, lastly, 
the patient very frequently forgets that she 
wears a pessary, hence the share of blame 
which the introducerof the in trument should 
bear is not uniform. 

When the patient is not aware that the 
instrument has been inserted, as is often the 
case, the medical attendant must undoubtedly 
have shown great skill and gentleness in in- 
troducing it, but he may not have taken 
sufficient pains to impress upon her memory 
the fact that the instrument has been in- 
troduced, and must not be worn for many 
months. This is the commonest cause of 
pessary accidents at the present time, for the 
art of introducing pessaries is readily acquired, 
experience is easily obtained, and the favorite 
pessaries are no longer barbarous instruments, 
whilst the patient may misunderstand such 
information as "I have passed a Hodge," 
or "You are wearing a Zwanck," and go 
away with the beleif that she is not wearing 
a pessary. As to the merits and disad- 
vantages of the almost innumerable forms 
of pessary, we must refer the reader to Dr. 
Neugebauer's valuable paper. The moral is 
that the introduction of a vaginal pessary is 
a minor surgical proceeding, but if performed 
carelessly may lead to results in no sense 
"minor," but, on the contrary, very serious. 
— Britsh Medical Journal. 

The Sensitiveness of the Peritoneum. 

Tait (Xance^!, January 21,1893) believes that 
the peritoneum ds exquistely sensitive, as 
shown not only by the severe pain ex- 
perienced by patients during a sudden internal 
hemorrhage, but by the agony which they 
suffer when it is necessary to open the abdom- 
inal cavity without anaesthesia. Moreover, 
he has frequently noticed that, on touching 
the peritoneum in women who were incom- 
pletely anaesthetized, reflex movements were 
frequently produced, indicative of the pain 
which was experienced. He addressed in- 
quires to several different abdominal surgeons, 
many of whom expressed an opinion directly 
contary to his own. Sutton believes that 
while the healthy peritoneum is not especially 
sensitive, when inflamed it is highly so. 

Suturing the Ureters. 

Trekaki {Gaz. des Hopitaux, 1892, No. 62) 
infers from experiments upon animals, as 
well as from the cases reported by Pozzi and 
Le Dentu, that patients do better when the 
proximal end of a wounded ureter is stitched 
into the abdominal wound than when it is 
turned into the rectum or vagina, since in 
the latter case infection may be carried to the 
renal pelvis, causing pyelitis. 



Vol. Ixix 

He suggests that in cases of suppuration of 
the kidney, instead of extirpating the organ, 
it should be exposed by the usual lumbar in- 
cision, and the ureter drawn out and divided, 
after ligating the distal portion, the proximal 
end being stitched into the wound. This 
operation would be indicated in cases of in- 
operable pelvic tumors compressing the 
ureter, after traumatic rupture of the duct, 
and even in cases of severe cystitis, in order 
to protect the kidneys (?). 


A Valuable World's Fair Book. 

The Passenger Department of the Baltimore 
and Ohio Railroad Company has prepared for 
general distribution a handsome pamphlet de- 
scriptive of the scenic and other attractive 
features of that road from New York to 
Chicago. This book should prove invaluable 
to those visiting the World's Fair. In its 
artistic cover, illustrations and reading matter, 
it is fully up to the high standard which has 
been fixed by the B. & O. for publications of 
this character. The scenery en route, which 
has gained for the B. & O. the richly deserved 
sobriquet of "Picturesque," the public build- 
ings at Washington, old Harper's Ferry,Luray 
Cavern, and other attractive points are 
faithfully portrayed. The value of the pub- 
lication is increased by descriptions and 
illustrations of the principal buildings at the 
World's Fair. This book can be procured free 
of charge lupon personal application to 
ticket agents, B. & O. R. R. Co., or you can 
have it mailed to you by sending name and 
address with five cents in stamps to Chas. O. 
Scull, General Passenger Agent, Baltimore, 
Md. World's Fair tourists should bear in 
mind that the B. & O. is selling tickets at 
very low rates good going via Washington 
and returning via Niagara Falls. 

Deer Park and Oakland. 

To those contemplating a trip to the moun- 
tains in search of health and pleasure, Deer 
Park, on the crest of the Allegheny Moun- 
tains, 3,000 feet above the sea level, offers such 
varied attractions as a delightful atmosphere 
during both day and night, pure water, 
smooth, winding roads through the moun- 
tains and valleys, and the most picturesque 
scenery in the Allegheny range. The hotel 
is equipped with adjuncts conducive to the 
entertainment, pleasure and comfort of its 

The surrounding grounds, as well as the 
hotel, are flighted with electricity. Six miles 
distant on the same mountain summit is Oak- 
land, the twin resort of Deer Park, and 
equally as well equipped for the entertainment 
and accommodation of its guests. Both 
hotels are upon the main line of the Baltimore 
and Ohio Railroad, have the advantages of 
its splendid Vestibuled Limited Express 
trains between the East and West and are 

most desirable resting places for World's Fair 
tourists. Season Excursion tickets, good for 
return passage until October 31st, will be 
placed on sale at greatly reduction rates at 
all principal tickets ofiicers thoroughout the 
country. One way tickets reading from St. 
Louis Louisville, Cincinnati, Columbus 
Chicago, and any point on B. & O. system to 
Washington Baltimore, Philadelphia, or New 
York, or vice versa, are good to stop off at 
either Deer Park or Oakland, and the time 
limit will be extended by agents at either 
resort upon application. 

The season at these popular resorts com- 
mences June 15th. 

For full information as to hotel rates, rooms,, 
etc., address George D. DeShields, Manager, 
Deer Park, or Oakland, Garrett County, 


U. S. ARMY FROM JUNE 25, 1893, TO JUI.Y 1, 


By direction of the President, Captain 
Marcus E. Taylor, Assistant Surgeon, will re- 
port in person to the president of the Army 
Retiring Board at Fort Logan, Col., when re- 
quired by the board, for examination by it. 

First Lieutenant Frank T. Meriw^ether, As- 
sistant-Surgeon, U. S. Army, is relieved from 
duty at Madison Barracks, N.Y., and ordered 
to Fort Logan, Colorado, for duty. 

Captain Louis A. La Garde, Assistant Sur- 
geon, will, in addition to his present duties in 
connection with the World's Columbian Ex- 
position, furnish the necessary medical atten- 
dance for the officers and enlisted men of the 
Army on duty at the Exposition grounds. 

Captain William C. Shannon, Assistant 
Surgeon, in addition to his duties at the office 
of the Surgeon General, is assigned to duty 
as assistant to the Attending Surgeon in this 

The leave of absence granted Major Wash- 
ington Matthews, Surgeon U. S. Army, is ex- 
tended one month. 

Captain Freeman V. Walker, Assistant 
Surgeon, now on leave of absence at the Army 
and Navy Hospital, Hot Springs, Arkansas, 
will proceed at once to Fort Trumbull, Conn., 
and report at once to the commanding officer 
of that post for temporary duty, relieving 
Major Henry M. Cronkhite, Surgeon. 

Major Cronkhite, upon being relieved by 
Captain Walker, will proceed to Fort Clark, 
Texas, and report in person to the command- 
ing officer for duty at that post. 

First Lieutenant Alexander N. Stark, As- 
sistant Surgeon, is relieved from duty at Fort 
Monroe, Virginia, and ordered to Fort Clark, 
Texas, for duty; relieving Captain Edgar A. 
Mearns, Assistant Surgeon. 

Captain Mearns, upon being thus relieved, 
will proceed to Nogales, Arizona, and report 
to the senior member of the commission ap- 
pointed for the location and marking of the 
boundary between Mexico and the United 
States, for duty with the commission. 

Vol. LXIX, No. 4. 
Whole No. 1899. 

JULY 22, 1893 

95.00 per Annum 
10 Cents a Copy 





Established 1853, by S. W. Butler. M. D, 

Entered as Second-Class Matter at Philadelphia P. O. 

P. O. BOX 843, PHILA, PA. 


Marie J. Mergler, M.D., Chicago, Illinois. 
What are the Indications for Removal of the Uterine 
Appendages? 117 


RoswELL Park, A. M., M. D. 
Recurrent Cancer, Talipes, Abscess of Xeck, Crani- 
otomy 121 


J. Wm. White, M. D., Philadelphia. 
The Present Position of the Hypodermic Method in 
the Treatment of Syphilis 124 

Charles B. Williams, A.B., M. D., Philadelphia. 
A Compound Dislocation of the Left Ankle, and Frac- 
ture of the Internal Malleolus — Astragalus and 
Internal Malleolus Excised 131 


The Medico-Chirurgieal Society, of Louisville. . 133 


The Prevention of Surgical Infection. ... 142 



SELECTED FORMUL/E . • . . . 150 








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Medical and Surgical 

No. 1899. 


Vol. LXIX— No. 4 




MARIE J. MERGLER, M. D., Chicago, Illinois. 

The student who has an opportunity of 
listening to the opinion of half a dozen 
clinical teachers on the subject of indica- 
tions for or against removal of uterine ap- 
pendages in a given case, will often be sur- 
prised at their variance. 

The patient who has suffered some time 
from dysmenorrhcea or from other pelvic 
pains, whether she seeks the advice of a 
number of the best general practitioners 
recommended to her at her home, whether 
she goes from one gynecological clinic to 
another, or whether, she consults as many 
of the "best specialists" as her purse 
can afford, is often equally surprised at 
the variance of the verdicts. She will 
sometimes be undecided for months, and 
even for years, as to what course to pur- 

One has told her " try to allay the in- 
flammation by local treatment and we 
can operate as a last resort." Another 
says: " Removal of the appendage is the 
only road to health ; delay is hazardous ; 
the risk of an operation nowadays is re- 
duced to a minimum.^' A third doctor 
says, " you will probably never regain 
health without the operation, but on the 
other hand you must take your own 
chances in choosing a measure which en- 
dangers life, and even then we cannot 
guarantee success." If this patient fol- 
lows the advice of the first, who said 

*Read before the Illinoi 

State Medical Association, 

" Wait," she may be rewarded by perfect 
health, sometimes on account of judicious 
treatment and sometimes without any 
treatment whatever; on the other hand, 
possibly she and her friends may regret 
the delay if she suddenly succumbs to an 
acute septic pelvic peritonitis. 

How about the patient who submits to 
the operation? She usually survives, fre- 
quently the ultimate result is all that has 
been promised ; but almost every physician 
can recall some particular case or cases in 
which she is even worse than before. 

I have in mind now one of these unfor- 
tunate ones who probably had consulted 
every gynecologist in this city, and who 
has tried to be admitted to the gynecolo- 
gical wards of several of our hospitals 
since her first operation. The ovaries 
had been removed for pelvic pain. She 
made a good recovery from the operation, 
but when she was able to be about the old 
pain returned with increased severity. 
For the vesical irritation of which she 
subsequently complained, the urethra had 
been dilated several times. One of the 
physicians treated her with electricity, 
but without success. Finally, removal of 
the uterus was suggested as a last resort. 
Whether she underwent this operation I 
do not know ; but my impression of the 
case is that no surgical operation could 
bring relief to her, on the contrary any 
measure which would lower vitality would 
aggravate the trouble, for she was suffer- 


Original Articles. 

Vol. Ixix 

ing with a neurosis of central origin. 

Those who have had a very large experi- 
ence, and who have watched their pa- 
tients for some years after the operation, 
will be able to select with considerable 
certainty the cases which may, or which 
inay not be benefitted, but it is to be re- 
gretted that those who have their experi- 
ence yet to gain, will find much in our 
literature that is contradictory and even 
misleading. I will except conditions in 
which the pathological changes are very 
conspicuous. On these there is no mater- 
ial difference of opinion ; for instance, the 
reader will hardly be in doubt as to the 
]n'opriety of removing ovarian tumors. 
The same applies to tubes which are con- 
siderably distended by fluid contents, or 
whose size is markedly increased by a 
neoplasm. Eemoval of the ovaries with 
the view of arresting the growth of some 
uterine fibroids is pretty generally sanc- 
tioned. The result in well selected cases 
is often most gratifying; the hemor- 
rhage ceases and the tumor gradually 

So much for indications which are gen- 
erally admitted. We come next to those 
which are the object of so much conten- 
tion; indications which, when rightly ap- 
prehended, have been the means of ines- 
timable benefit, but which, when misap- 
|)rehended, have brought upon the san- 
guine operator the criticism of his brethren 
and the disappointment and sometimes the 
curse of his patient. 

The indications just referred to are as 
follows: Inflammatory conditions of the 
ovaries or tubes, displaced and enlarged 
appendages, dysmenorrhoea, menorrhagia, 
epilepsy, hystero-epilepsy and various 
other neuroses. 

My own observation has led me to con- 
clude that the skepticism concerning op- 
erative gynecology in general and the util- 
ity of removing uterine appendages in 
particular, is not without foundation. 
After all that has been written in this 
country and abroad in favor of conserva- 
tism, and against ^' too much surgery,'^ the 
lessons are still too often left unheeded. 
For, on the one hand, claims of success are 
made in premature reports which do not 
stand the test of time ; on the other, indi- 
cations are imagined when they do not re- 
ally exist. Those who assume the respon- 
sibility of deciding when it becomes neces- 
sary to remove the uterine appendages, may 

profit by a careful study of the writings 
of Doleris, Olshausen, Hegar, Lusk, 
Polk and others who have given this sub- 
ject conscientious and careful considera- 

A thorough acquaintance with the works 
of standard authorities is one of the es- 
sentials to success ; but even more essen- 
tial than this is an accurate knowledge of 
the normal and pathological anatomy of 
the pelvis, and the acquisition of consider- 
able skill in physical diagnosis. In the 
majority of cases where unnecessary oper- 
ations have been advised, or where opera- 
tions have been performed with very dis- 
appointing results, I believe it has been 
due to one of the following causes: 

1. Too hasty decision to operate. 

2. Mistaking functional disturbances of 
the appendages for primary lesions. 

3. Mistaking hereditary taints and cer- 
ebral neuroses for the direct reflex of a 
local and acquired pelvic disease. 

Too Ha$ty Decision. I recall at least a 
score of patients who have come to me from 
other physicians, on whom an operation 
had been urged as necessary,and who sub- 
sequently regained excellent health with- 
out it. One of these had been seen but 
once, examined hastily and told to go to 
one of our hospitals as soon as possible for 
removal of the ovaries. Yery much wor- 
ried, she went home, had a good cry and 
then concluded to see what another would 
advise. I had no knowledge of her pre- 
vious experience when she consulted me. 
I diagnosed the case as endometritis with 
slight parametritis, and gave the patient a 
good promise as to recovery, but a guarded 
one as to time. I noticed at the time the 
patient asking rather anxiously "^ if her 
ovaries were not diseased " but failed to 
suspect a reason for anxiety. Her digest- 
ive function was very much disordered, she 
suffered with a severe headache, and her 
general nutrition was below par, as is usual 
in these cases. Six weeks of rest in bed, 
douches, careful dieting and tonics made a 
different woman of her. Her menstrua- 
tion was painless, she could digest simple 
food and had gained in flesh ; her head- 
ache was better but not entirely relieved. 
Suspecting eye strain, I sent her to an oc- 
ulist, who fitted her with glasses which 
improved her head symptoms materiaDy. 
This was two years ago ; she is still in good 
health, and, when I saw her about a month 
ago, was pregnant. 

July 22, 1893. 

Original Articles. 


Another case was one of well marked 
salpingitis and ovaritis. She had entered 
a hospital m a neighboring state and had 
made all preparations for removal of the 
appendages, but when the time of the 
operation arrived she lost courage and 
fled. As there was considerable swelling 
of the right tube, and she stated she had 
been a sufferer for many years, I told her 
frankly it was very doubtful if anything 
but an operation would help her, but if 
she was willing to put herself under treat- 
ment for six or eight months she might 
improve sufficiently to make an operation 
unnecessary. Nine months from that 
time she went home apparently well, and 
had continued to feel well for two years 
when last I heard from her. 

Inflammatory conditions of the ovaries 
so frequently yield to judicious treatment 
that in every instance it should have a 
fair trial before the radical operation is 
urged. The same applies to inflamed tubes. 
Catarrhal inflammation of the mucosa of 
the tubes is usually simply an upward ex- 
tension of an endometritis, and both may 
be self-limited. The infectious form is 
more obstinate and more likely to under- 
mine the general health, and, indeed, often 
threatens life. Bu t even in these cases if 
the conditions for drainage are favorable, 
recovery without removal is possible. 
Eest, antiphlogistics and drainage will 
often accomplish wonders. I admit that 
the cases of ovaritis and salpingitis due 
to infection, may at some time or other 
unexpectedly light up an acute pelvic 
peritonitis which proves fatal, yet this 
can hardly be regarded as an unqualified 
indication for immediate removal, for the 
number of actual deaths from that cause 
is very small in proportion to the number 
of appendages thus diseased. 

The discomfort due to displaced ovaries 
is very frequently amenable to milder 
measures, especially where no firm ad- 
hesions exist. Neither displacement j^er 
se, nor enlargement of one or both ovaries 
are indications for removal. Both may 
be the natural censequence of a retro verted 
uterus, and all the bad symptoms and the 
enlargement will subside as soon as that 
organ is replaced and kept in position. 
Marked ovarian enlargement, associated 
with grave local and reflex disturbances, 
may be very transient. It is usually due 
to venous stasis and is particularly 
noticeable just before the menstrual period. 

The following was to me an instructive 
case some years ago. I was called to the 
country to see a patient and her daughter. 
The latter was lying in bed suffering with 
severe pelvic pains. The mother stated 
that the girl, who was fourteen years old 
had never been well ; that she had men- 
struated for the first time six months 
previous, and since that time had par- 
oxysms of severe pelvic pain associated 
with great mental depression. The girl 
seemed very anemic and not well de- 
veloped physically, and had been subject 
to constiption. On making a pelvic ex- 
amination I found a small retroverted 
uterus, and the right ovary of the size of 
a large hen's Qgg^ prolapsed and very 
tender. The uterus could be easily re- 
placed. The ovary was so large and re- 
sistant that I took it to be a small der- 
moid, but requested the patient to call at 
my office in a few weeks for a second 
examination. In the meantime I pre- 
scribed iron and laxatives. When she 
presented herself a month later, the ovary 
was normal in size and the pelvis free 
from pain. The patient had menstruated 
soon after my first visit. The enlarge- 
ment in this case must have been due to 
the displacement and premenstrual con- 

Mistahing Functional Disturlances Due 
to Other Causes for Primary Disease of 
the Ovaries aud Tubes. — Women whose 
general nutrition is disturbed, or those who 
are subject to great nerve strains, and 
those who are overworked and underfed 
are very likely to suffer from dysmenor- 
rhoea. Strict attention to diet, change of 
occupation and rest are indicated in these 
cases, and will often remove the difficulty 
without any local treatment whatever. 

I have known functional disturbances, 
particularly dysmenorrhoea and menor- 
rhagia due to the lithic diathesis or consti- 
pation, to be mistaken for chronic ovaritis. 

Hastening the menopause by removal of 
the appendages would hardly be the most 
scientific treatment in these cases. 

Mistahing Hereditary Taints and Cen- 
tral Neuroses for the Direct Reflex of a 
Local and Acquired Pelvic Disease. The 
removal of the ovaries and tubes has been 
practiced successfully for severe forms of 
epilepsy, hystero-epilepsy and different 
forms of psychoses; but it is very essential 
before considering this measure in a given 
case, to determine whether these neuroses 


Original Articles. 

Vol. Ixix 

are really reflexes of genital origin, or 
whether onr patient is haunted by the 
ghosts of a neurotic ancestry. Should the 
latter be the case, the removal of the 
ovaries will aggravate the neuropathic 

Some authorities claim that this opera- 
tion is only justifiable where we can dem- 
onstrate the presence of ovarian disease by 
physical examination. Other equally 
good authorities claim that, since grave 
psychical and other reflex disturbances do 
occur in cases where the seat of the lesion 
could not be previously determined, the 
operation is in some of these cases justifi- 
able, since the field for this operative in- 
terference is still to be determined to some 
extent in an experimental way. This be- 
lief, however expressed by men of large 
experieiice who have given the subject 
careful study in all its phases, offers no 
excuse for hasty decision, without ac- 
quainting patients and their friends of the 
comparative uncertainty as to the results 
in this particular class of cases. Nor does 
it justify the proceeding to the removal 
of organs about whose size, form and pos- 
ition the advisor does not even pretend to 
have any definite knowledge. This I 
have known to be done. Unfortunately, 
it is much easier to acquire the technique 
of the operation than the judgment of 
when to operate. 

In conclusion, up to the present time 
the experience of our best authorities 
would define the legitimate limits of the 
operation as follows : 

1. Existence of neoplasms in the ap- 

2. Hernia or prolapse of the ovary, 
when irreducible and when producing 
urgent symptoms which do not yield to 
palliative treatment. 

3. To the arrest of the growth of uter- 
ine fibroids. Here the limits can hardly 
be said to be definitely fixed. As a rule, 
however, the operation may be taken in- 
to consideration for tumors which are sub- 
mucous or interstitial, before the uterus 
has attained a great size (Olshausen puts 
it at the size of a four months pregnancy). 
It may also be considered in fibroids when 
the symptoms are urgent and when either 
on account of cardiac weakness or from 
the presence of nephritis, so common in 
fibroids, the more radical though more 
dangerous, operation of laparo-hysterect- 

omy would be attended with too much 

4. Inflamed conditions of the append- 
ages, whose symptoms render the patient's 
life a burden, and which have resisted a 
fair trial of palliative treatment. These 
conditions when complicated by extensive 
adhesions of the organs, are less likely to 
yield to mild measures. Even in these 
cases the breaking up of firm adhesions, 
after abdominal section without removal 
of the ovaries and tubes, has been followed 
by relief of the symptoms. 

5. The presence of pus in the ovary 
and encysted pus in the tube, as a rule re- 
quire the radical treatment. 

6. Marked reflex neuroses whose origin 
may be traced directly to diseases of the 

These indications can be but general 
guides ; an inflexible rule cannot be laid 
down. Every case must be studied by 
itself and at all times removal should be 
regarded as the last resort. 

A Slight Mistake. 

An instance where a bad cold caused a 
startling conversation. 

There is a joke being told here at the 
expense of a modest young newspaper 
man in a neighboring town which is so 
good it ought to be true, says the Bristol 
News. The young man in question, it 
appears, was recently invited to a party at 
a residence where the home had recently 
been blessed with an addition to the fam- 
ily. Accompanied by his best girl he met 
his kind hostess at the door, and after 
customary salutations asked after the 
welfare of the baby. The lady was suf- 
fering from a severe cold, which made her 
slightly deaf, and she mistakenly supposed 
that the young man was inquiring about 
her cold. She replied that though she 
usually had one every winter this was the 
worst she had ever had; it kept her 
awake at night a good deal at first and 
confined her to her bed. Then noticing- 
that the scribe was becoming pale and 
nervous, she said that she could see by his 
looks that he was going to have one just 
like her's and asked him if he wished to 
lie down. 

The paper came out as usual the next 
week, but the editor has given up inquir- 
ing about babies. 

July 22, 1893. 

Clinical Lectures. 




I am about to show yon a case of disap- 
pointment, not to me but to the patient, 
who came here yesterday from a distance 
for the purpose of submitting to opera- 
tion for recurrent cancer of the breast. 
The trouble was first noticed last Jan- 
uary; on March 26, the entire left breast 
was removed and in May, pain began to 
be felt in the arm as if there were rheu- 
matism. At the present time, ten months 
after the inception of the disease, there is 
great limitation of motion in the left arm. 
You can see the scar of the operation on 
the chest, but I find no scar in the axilla 
where I should like to, because I 
make it a rule always to clean out the 
axilla in a case of malignant disease of the 
breast whether involvement of the lymph- 
nodes is apparent or not. The disease has 
evidently extended to the tissues about 
the brachial plexus and I have told the 
patient that any operation that would be 
eflficient, would probably be fatal because 
there is so much to be removed. Disar- 
ticulation at the shoulder — as recom- 
mended by Esmarch — would be necessary 
and even this would probably not eradi- 
cate the disease. There is no history of 
hereditary predisposition to malignant 
disease except that a maternal aunt died 
of what was in all probability cancer. 

The case not being operable, I have 
suggested inoculation with erysipelas, a 
procedure which has been found to be 
followed with beneficial results. 

This child, eighteen months of age, has 
a mild club-foot which requires a sever- 
ing first of the tendo Achillis, because 
the toes can not be drawn up, and then 
of the plantar fascias or possibly of one or 
two flexor tendons, in order to overcome 
the excessive arching of the foot. There 
is also some tendency to inversion but the 
main trouble to relieve is the shortness of 
»the tendo Achillis. You can readily 

••■Prof, of Surgery University of Buffalo; Surgeon to 
Buffalo General Hospital. 

supply the technical name of the de- 
formity — talipes equino-varus. 

After performing tenotomy I find that 
the foot can be brought up in flexion 
but the tightness of the plantar fascia 
still requires relief and I now divide that 
structure subcutaneously, passing the 
knife outward through a small opening at 
the inner side of the arch of the foot. 
The foot can now be restored to its nor- 
mal position and I shall dress it with a 
starch bandage. You notice that even 
now, although the foot can readily be 
placed in the normal position, the inner 
tendons pull it back into the old defor- 
mity just as a horse's head is pulled to 
one side by a bridal rein. After the 
wounds have healed, it will be necessary 
to resort to massage and electricity, ap- 
plied to the peronei so as to tighten the 
loose bridle rein and bring the foot 

Seven months ago I operated on this 
young woman, who had been walking on 
the external malleolus on account of a bad 
form of club-foot. Over the malleolus 
had developed a large bursa — an instance 
of a cyst of new formation serving a con- 
servative purpose. The sole was turned 
up against the other foot. The operation 
of astragalectomy was made as aseptically 
as possible and the limb was done 
up in a plaster dressing. There is still a 
little soreness of the foot when the patient 
walks too much but otherwise she has no 
trouble. You notice that the foot is 
shorter than the other. This is not due 
to the operative interference but to pre- 
vious failure to develope from non-use. 
The shoe worn is like that on the other 
foot except that the heel is raised a trifle 
to compensate for the shortening of this 
limb. If I had done an ordinary teno- 
tomy here and then relied on a club foot 
shoe to correct the deformity, the same 
result would have been attained after two 
or three years. In as many months she 


Clinical Lectures. 

Vol, Ixix 

has as good a foot from the severer 
measure of removing one of the tarsal 
bones in order to straighten the foot. It 
is a result such as this that justifies the 
more radical operation. The patient has 
not yet recovered by any means as much 
use of the foot as she will later, for she is 
old enough to aid the surgeon by intelli- 
gent co-operation. In the little child on 
whom I did a tarsectomy four weeks ago, 
the starch dressing was left on two weeks 
and a half and then replaced by a plaster 
bandage. After that is removed, it will 
be necessary to keep on a club-foot shoe 
for some months as the child can not be 
relied upon to make the voluntary effort 
to roll the foot outward and to "toe out."" 
"■ As the twig is bent, the tree is in- 
clined " and, in applying this old maxim 
to orthopaedic surgery, we must bear in 
mind the necessity of maintaining the 
corrective impression night and day. In 
the case of the little child, direction 
must be given to the parents to keep the 
club-foot shoe on continually except as it 
is occasionally removed for a few minutes 
to allow massage or for purposes of clean- 

This child, eighteen months old, has 
been brought here with a swelling in the 
neck which has enlarged rapidly in the 
last few days. On examination I find 
fluctuation and presume that the case is 
one of acute inflammation of some of the 
cervical lymph nodes. When such a case 
presents itself to you and there is no 
ostensible reason for the enlargement, I 
would advise you to examine the teeth, 
the tonsils and the ears to see if there is 
any septic process which may account for 
involvement of the adjacent nodes. 
Failing to find an explanation from this 
examination it would be well to turn 
your attention to the scalp, for eczema of 
this region may be accompanied by inflam- 
mation of the lymph nodes. The tonsils 
are like sponges, having crypts which re- 
tain infectious debris,and there may follow 
systemic symptoms from the absorption of 
this material. Such absorption takes 
place through the lymph vessels to which 
the lymph nodes bear the relation of fil- 
ters. It is in the nodes, therefore, that 
septic material is retained and suppuration 
is set up. If the infectious material is 
tubercular, a tuberculosis of the lymph 
nodes results which has been called scrofula. 

Now in such an inflammatory tumor as 
this, with fluctuation and the tenderness 
which was manifest before the child was 
anaesthetised, we can be confident that 
we have an abscess and I do not think it 
would be a mistake to make free incision 
into it. But in order to demonstrate 
absolutely that the tumor is not an 
aneurism or a soft mass not containing 
pus, I will follow for your benefit the 
absolutely safe method of first introducing 
a fine needle connected with a syringe by 
means of which pus is removed. The 
indication for free drainage is clear. You 
will notice that the field of operation is 
rendered aseptic before the knife is used. 
This may not be necessary since we expect 
to have it flooded with infectious matter, 
but few patients who are brought to a 
hospital are injured by the application of 
water, the use of the antiseptic solution 
causes only a moments delay, and we can 
be sure that, if further signs of sepsis 
develop, they are due to internal sources 
and not to any germs that we have intro- 
duced. This abscess seems quite exten- 
sive and I may have to scrape it out, so 
that an incision at least an inch long will 
be necessary. I shall follow one of the 
creases in the skin so that the scar may 
not show after it has healed. You might 
say that in cutting transversely I am in 
greater danger of dividing vessels, but 
the abscess is immediately below the super- 
ficial fascia and there are no large vessels 
to be encountered. My finger goes into 
a cavity the size of a robin's Qgg after a 
considerable quantity of pus has been 
evacuated. The walls of the cavity are 
thick and tough but do not require so 
much scraping as I had anticipated. The 
cavity is washed out with a hydrogen per- 
oxide solution. 

On examining the child I have found 
nothing wrong in the mouth or throat and 
the ears and scalp are apparently healthy. 
There must be an underlying cause for 
every abscess, but I discover none here. 
Alterative tonics will be administered, 
the wound will be dressed daily with a 
little tent of iodoform gauze to prevent 
the adhesion of the fresh raw edges until 
the cavity beneath has closed by granu- 

This patient is a little imbecile child on' 
whom I purpose to perform the operation 
of craniotomy. The word craniotomy in 

July 22, 1893. 

Clinical Lectures. 


this connection has not its obstetrical 
meaning, but is used in the literal sig- 
nificance of cutting the cranium. The 
object of the operation is to divide the 
skull in such a way as to enlarge its ca- 
pacity and allow the brain to expand. 
The term craniectomy has been more re- 
cently applied to this operation, but as we 
cut out nothing but the narrow strip of 
bone that corresponds to the width of the 
saw, I think that craniotomy is the prefer- 
able term. The operation consists typi- 
cally in making a ]inear,]ongitudinal open- 
ing in the skull as near the middle line 
as is possible without wounding the supe- 
rior longitudinal sinus. The opening I 
prefer to make on the left side, because 
it is on that side that the centres of 
speech and those governing the move- 
ments of the right side of the body are 
located. In the present case I expect to 
do more than the usual operation, intend- 
ing to extend the incision in a semicircle 
or horse-shoe, and spring up quite an area 
of the side of the skull. This lid or oper- 
culum will not be cut loose from its vascu- 
lar connections^ for the soft parts will re- 
main attached to it, and as the bone itself 
is not broken entirely loose, there will re- 
main a hinge or bridge containing an 
abundant supply of blood vessels to sup- 
ply nutrition. You have recently seen 
another case of craniotomy in which a Y- 
shaped incision was made, and you know 
that, whatever the manner of separating 
the skull, the object of the operation is to 
afford a relief from intracranial pressure. 

We have had great difficulty in shaving 
this child's head, for he would not keep 
still. Except during sleep, most of his 
time is spent in jumping up and down 
on his hands and knees in his crib, play- 
ing a kind of idiotic leapfrog with him- 
self. It has been noticed that the child's 
radial pulse is good on one side and 
scarcely distinguishable on the other, so 
that there must be some anatomical anom- 

Under chloroform anaesthesia, the head 
is shaved and then cleansed with a mix- 
ture of turpentine, alcohol and ether to 
remove the sebaceous matter.^ The field 
of operation is now irrigated with a bichlo- 
ride solution and the head bound by an 
Esmarch ligature to prevent loss of blood 
as far as possible. Towels wrung out of a 
bichloride solution are used to protect the 
shaved scalp from the encroachment of 

septic germs from the face and neck. The 
operation will proceed under ether anaes- 

The first incision is in the form of a 
semicircle, seven cm. in diameter, about 
the left parietal eminence. If I were 
making an ordinary trephining, I should 
now dissect up this semicircular flap; but, 
as its vascular connection with the bone 
must be maintained, access to the skull 
is obtained by dissecting away the scalp to 
the outer side of the incision, and, for the 
sake of greater freedom, a connecting in- 
cision, extending straight backward, is 
made. With theDeVilbis saw a groove is 
marked in the bone. I shall work with 
chisel and bone-punch in this groove. It 
is a term of reproach to call an individual 
thick-headed, but the epithet seems to 
have an anatomical justification, for al- 
most every idiot on whom I have operated 
has had an abnormally thick skull. In 
order to be able to handle the tools intelli- 
gently,! am going to learn the exact thick- 
ness of bone in this case by means of the 
trephine. The small button of bone 
which is removed measures 5 mm., quite 
an ambitious thickness for a boy of six. 
Into a skull of this thickness and density 
the saw would penetrate about as quickly 
as it would into a piece of marble. It is, 
therefore, practically useless except to out- 
line the work for the other instruments, 
and, though I have no great liking for the 
chisel, it will be necessary to use it in this 
case. As the bone is penetrated, iodoform 
gauze is stuffed into the wound to exclude 
septic material and to prevent oozing from 
the bone. 

I have now succeeded in cutting 
through the entire length ol the groove 
and the horse-shoe shaped trap- door is 
pried up with a lever. With the closely 
approximated poles of a faradic battery, I 
am trying to produce a muscular response 
to the excitation of the mother centers in 
the cerebral cortex. Ordinarily this can 
be done through the dura mater, but in 
this case there is no response. There is 
considerable tension of the dura and I 
shall divide it parallel to the course of the 
majority of vessels which are visible, so 
as to avoid hemorrhage as much as possi- 
ble. I can get no response to the electrical 
stimulus even when nothing but the pia 
and arachnoid intervenes. The tension of 
the brain is very evident from the way in 
which it protrudes through the opening in 



Vol. Ixix 

the dura. Although the pressure has 
been relieved over this area, it is hopeless 
to expect a skull as thick as many an 
adults' to expand sufficiently to allow the 
proper development of the entire brain. 
The antipyrin spray (5 per cent.) is used 
to control hemorrhage and the dura is 
closed with fine cat-gut. The lid of 
bone is laid in place and the scalp wound 
sutured with cat-gut and dressed anti- 
septically. It will probably be necessary 

to keep the child's hands lashed in order 
to prevent him from tearing off the dress- 
ings. The immediate prognosis is favor- 
able, the pulse is better now than it was 
when the child entered the hospital and 
there is no reason to anticipate any trouble 
from the surgical interference. We can 
hope for a slight mental improvement and 
even that will be an important gain, but 
the prognosis, so far as perfect mentality 
is concerned, is decidedly unfavorable. 



J. WM. WHITE, M. D., Philadelphia, 

While the use of hypodermatic injec- 
tion in syphilis dates back nearly thirty 
years, the alleged superiority of this 
method of treatment to all others has 
been most persistently set forth by its 
advocates during the last ten years. 
Their arguments are based primarily upon 
the shortcomings of the methods of mouth 
ingestion and inunction, and further upon 
certain alleged advantages claimed for the 
hypodermatic method itself. 

The specific claims made by those who 
have been exploiting the method are as 
follows (Sukhoff, Damman, Elsenberg, 
Lang, Blazer, Lewin) : 

1. The practitioner remains "master of 
the situation" throughout. This is one 
of the glittering rhetorical generalities 
indulged in occasionally by our Continental 
colleagues, which may mean anything 
or nothing, and to which a de- 
finite reply is always difficult. In this 
instance, under the most limited inter- 
pretation possible, it is not warranted by 
the facts. 

2. The drugs needed may be easily ob- 
tained in the pure state. This is not 
peculiar to the hypodermatic method. 

3 . They may be prepared for use by the 
physician himself. This, if ever an ad- 
vantage, is scarcely worth mention. 

4. In the use of the soluble salts of 
mercury a precise dosage is obtainable. 

* Abstract from Transactions of Philadelphia County 
Medical Society. 

It may be safely asserted that the varying 
degrees of local reaction affecting the 
rapidity and the thoroughness of absorp- 
tion do not give rise to as much variation 
in the dose as do the differences in absorp- 
tive power in the skin and the gastro- 
intestinal mucous membrane. 

5. It saves time and labor on the part 
of both physician and patient, rendering 
visits more infrequent, etc. This is doubt- 
ful, and not very important, if true. 

6. It necessitates but little alteration in 
diet, habits of life, etc. Such alteration, 
under ordinary methods, is practically only 
that indicated by the general rules of 
hygiene, and would be beneficial to most 
persons, non-syphilitics included. 

7. The patient's skin and digestive 
organs remain unaffected, except in rare 
instances. This is true, but is offset by 
the pain, the liability to abscess, and other 
objections to be described later. 

8. Stomatitis is of rare occurrence. 
This is not correct. The evidence goes to 
show that with equal care it is more likely 
to occur during hypodermatic medication, 
and when it does occur comes on more 
suddenly and is more intense and un- 
controllable than under either of the 
other methods. 

9. It enables the patient to conceal the 
disease. This may have some little force 
when the method is compared with the 
inunction treatment, but is certainly a 
very minor point in any event. 

July 22, 1893. 



10. It lessens expense. This is likewise 
of little importance, as the difference is 
not great. 

11. It is more likely to affect an entire 
and permanent cure, and does so in the 
shortest time and with the minimum 
amount of mercury. This is, after all^ 
the most important claim that is made, 
and if it could be established would 
warrant the adoption of the method to 
the exclusion of all others. I am of the 
opinion, however, that it cannot be sub- 
stantiated, and at -any rate am certain 
that the time has not yet arrived for a 
final and judicial decision upon the 
matter. The evidence is contradictory, 
and is open to the suspicion of bias upon 
both sides, but especially and notably 
upon that of the advocates of hypoder- 

12. In the presence of grave and immi- 
nently threatening visceral troubles it 
affords the readiest and surest way of pro- 
ducing a powerful influence. This may 
possibly be admitted, although in the 
great majority of cases there is ample 
time for the employment of inunctions. 

13. In doubtful cases it shortens the 
time required for the "therapeutic diag- 
nosis.^' This is scarcely to be included 
among the advantages belonging to a 
system intended for routine treatment. 
It is especially claimed for the hypoder- 
matic use of calomel, and will be discussed 
in connection with that drug. 

The objections to the method may be 
more briefly mentioned, as I believe they 
are all well founded. 

1. It is painful, and in many patients 
excites apprehension, and is strongly ob- 
jected to. It might be added that the 
measures advocated to obviate or lessen 
pain, viz., the precedent or simultaneous 
administration of morphine or cocaine, 
are in themselves highly objectionable, 
and certainly to be discouraged. 

2. It is occasionally, though rarely, 
dangerous, and sometimes rapidly fatal. 
This is undoubted. 

3. It is liable to be followed by certain 
local complications, which are : {a) 
erythema; {V) painful nodosities; (c) 
cellulitis ; (<^) abscess ; (e) sloughing. 

While the percentage of these troubles 
is small in the reported cases, it must be 
remembered that the bulk of the enor- 
mous mass of literature referring to it 
which has accumulated during the last 

decade has been contributed by partisans. 
This prevents me from being much in- 
fluenced by figures showing, for example, 
that ''in 36,922 injections in 3185 
patients, suppuration occurred in 116, or 
less than one-third of one per cent." 
(Damman: Aust. Med. Jour.^ March 15, 

4. It cannot be properly carried on by 
the patient, but always requires the inter- 
vention of the surgeon. In attempting 
to review the contributions to this depart- 
ment of syphilology I shall not attempt 
completeness, both because of lack of 
space and for the reason that so much 
that has been written is, if not stale and 
flat, certainly weary and unprofitable. 

The chief subdivisions of the hypoder- 
matic method are based upon the solu- 
bility or insolubility of the mercurial pre- 
parations which are employed, the lead- 
ing member of each group being respec- 
tively the corrosive chloride and the mild 

The technique of their introduction is 
practically identical in both classes. 

(a. )The solution or emulsion used should 
be sterilized. 

{}).) The skin of the region selected for 
the puncture should be cleansed with soap 
and water, then with alcohol or turpen- 
tine, then with a 1 to 20 carbolic solution, 
and finally with 1 to 1000 sublimate solu- 
tion. The hands of the operator should 
be similarly prepared. 

(c.) The needle, which should be larger 
and longer i;han the ordinary hypoderma- 
tic needle, and the syringe itself, should 
be washed in 1 to 20 carbolic solution for 
at least fifteen minutes before using. 

Any form of syringe may be employed, 
the essentials being that it is capable of 
complete sterilization, works easily and 
smoothly, and holds the necessary quantity 
of fluid. For some of the preparations 
employed a rubber syringe and a silver or 
gold needle are of advantage. Por many 
of them the ordinary hypodermatic syr- 
inge, with the larger needle, will suffice. 

Much has been written about the site of 
injection and its depth. There seems rea- 
son to believe that the local influence of 
mercury is of great advantage, and the 
existence of a serious lesion at an accessi- 
ble locality may occasionally determine 
the point of injection. Usually, however, 
the post-trochanteric region has been 
chosen as one which is not subject to pres- 



Vol. Ixix 

sure or to the observation of others, and 
which is not especially sensative. The 
statement has been made (Taylor, op. cit.) 
that experience shows the thighs to be 
particularly liable to undergo suppura- 
tion, and that they should therefore be 
avoided. The same advice is given as to 
the arms and forearms. The only a 
priori reason which occurs to me in ex- 
planation is that the constant use and 
motion of these parts may favor inflam- 
matory changes. They would naturally 
be selected frequently under ordinary cir- 
cumstances for hypodermatic medication, 
and the fact of their special susceptibility 
to abscess ought to be fully demonstrated 
before they are excluded from the list of 
available sites. The regions where the 
skin is closely applied to bones, those 
where cellular tissue is scanty and those 
subjected to pressure in ordinary positions 
should be carefully avoided, as should 
those in which suppuration or sloughing 
would be followed by noticeable disfigure- 
ment. As to the depth at which the in- 
jection should be deposited, " the choice 
lies between the muscular tissues and the 
subcutaneous connective tissue. In my 
judgment the preference should undoubt- 
edly be given the latter, as if abscess oc- 
curs it is much more easily managed than 
if it is subfascial. 

The method of throwing in the fluid is 
identical with that of giving an ordinary 
hypodermatic injection. A fold of skin 
should be pinched up and the needle in- 
troduced parallel to its long axis and to 
the required depth. The point of punct- 
ure should be covered with the finger of 
the operator as the needle is withdrawn, 
and then sealed with a little iodoform in 

All these precautions cannot prevent 
occasional microbic infection from the 
deeper layers of the skin, and unless the 
fluid used happens in itself to be antisep- 
tic, this accident will be followed by cellu- 
litis or abscess. 

We may consider the special substances 
used in the two great groups. 


{a). Corrosive sublimate. — The dose is 
from T2 to I of a grain dissolved in about 
20 drops of distilled water. It may be 
given in an average case every second or 
third day until stomatitis is threatened, 

and may then be used at longer intervals. 
If selected on account of some emergency, 
larger or more frequent doses may be em- 
ployed . ' 

{h). Asparagin: Mercury. — Two and a 
half drachms of asparagin is dissolved in 
warm water, and oxide of mercury added 
to saturation. The solution is filtered 
after cooling, and the amount of mercury 
estimated. It is then diluted to make a 
1 or 2 per cent, solution of mercury as re- 

(c). Succinimide of mercury, used in a 5 
per cent, aqueous solution in doses of ijo to 
A of a grain. 

(d). The oxy cyanide has been used by 
Boer in 1 gramme (15 grains) injections, 
containing 1.25 per cent, of the mercurial. 

(e). Mercuric Albuminate. — An un- 
stable compound of white of egg^ sodium 
chloride and sublimate ; of indefinite com- 
position and liable to rapid deterioration. 

(/). The lodo-tannate of mercury 
(Nouny) may be used in the following 

T>, Hydrargyri gr. 1-16 

XV lodini gr. i^ 

Acid, tannic gr. 3-10 

Glycerine gtt. xv 


{q). Carbolate of mercury has been used 
by various experimenters in doses of -^ to ^ 
grain dissolved in 15 drops of water. 

{h). The formamide of mercury. 

{%). Alaninate of mercury. 

[j). The benzoate of mercury is pre- 
ferred by Balzar and Thiroloix {La Med. 
Moderne) who &Sij: "this salt coagulates 
albumen far less than other combinations 
of mercury, and hence it exercises a less 
energetic action upon the cutaneous nerve- 
filaments. It does not seem to cause 
gastro-intestinal complications or ab- 
scesses, and no case of gingivitis ever 
went on to marked salivation. The in- 
jections may be practiced in any part of 
the body, but are less painful in the back. 
The objections to this salt are that 
many injections are required, that "' it 
deteriorates on keeping, and that it some- 
times causes induration at the point of 
application. Oochery {These de Fan's, 
1890) says that the fact that the benzoate 
does not coagulate albumin is the explana- 
tion of its comparative painlessness. He 
found that this, like other preparations, 
is not well borne by very stout persons, 
the presence in the connective tissue 
spaces of masses of fat preventing the 

Julv 22, 1893. 



satisfactory diffusion of the remedy. 
The same observations have been made by 
others. Bronsse, of Montpelier, prefers 
this salt to all the other soluble prepara- 


(a). Calomel, which may be taken as 
the type of the insoluble preparations^ 
may be used in the dose of one-half to one 
grain every four days, two grains weekly, 
or three grains every ten or twelve days. 
It may be given in one of the following 

T>. Hydrarg. chlorid. mit gr. 3^. 

XV Glycerinae purificat gtt. x. 

Aquse destillat gtt. x. 


T>. Hydrarg. chlorid. mit gr. j. 

X)& Mucilag. acaciae gtt. xx. 


"O. Hydrarg. chlorid mit. I 

iS^ Sodii chloridi \ ^a S'-J- 

Aquae destillat gtt. xxx, 


The calomel used should be sublimated 
by steam and perfectly sterile. 

The method in use by Besnier at the 
Hopital Saint Louis may be taken as the 
type, and is, therefore, given in detail: 
The formula used is calomel, 1 part, oil 
of vaseline, 20 parts. The calomel is in- 
corporated with the petro-vaseline and 
well shaken, to put the insoluble substance 
in as perfect suspension as possible, and 
the mixture is then boiled a few seconds 
before making the injection, in order to 
sterilize it. The operator should wash the 
hands in a mixture of alcohol and liquor 
of Van Swieten, and cleanse the part 
where the injection is to be made with 
some absorbent cotton wet with the same 
solution. The needle of the syringe 
should be cleansed. The choice of loca- 
tion for making the injection is a point of 
the buttocks, about three centimeters 
below the crest of the ilium and an equal 
distance above and to the inner Side of 
the great trochanter. The mass of 
muscles in this region are favorable for 
the injection, and they do not support 
the weight of the body in sitting. The 
skin is displaced somewhat, so that there 
is no direct continuation of the puncture 
of the integument and that of the deeper 
tissues. The iusertion of the needle is 
done quickly at one stroke down to the 
guard. By operating in this way the 
patient scarcely feels its introduction. 
The injection is then made gently, bnt a 

certain force must be employed to secure 
a passage of the emulsion into the tissues. 

The employment of calomel subcutane- 
ously was originally advocated by Scareu- 
zio in 1864, but was not very extensively 
used, except in Italy and Germany until 
the writings of Smirnoff in 1883 and 1886 
called renewed attention to it. 

During the interval, Sigmund was the 
most prominent syphilographer who care- 
fully investigated the claims which were 
made for it, reaching the conclusion that 
we cannot hope to "cure " syphilis by a 
few injections of this or any other salt of 
mercury. Since then it has been used 
very largely, and its limits of usefulness as 
well as its dangers are now fairly well 

We may consider the latter first. 

Locally, there is almost always pain of 
greater or less severity. 

There is almost always an inflammatory 
reaction, which, when slightly developed, 
causes merely a flush around the needle 
puncture, and a feeling of heat or itching. 
Lasser has reported a case of extensive 
mercurial erythema. Oftener there is an 
exudation of lymph with the formation of 
a hard, horny nodule, moderately tender 
to the touch and very painful if subjected 
to continuous pressure. This is usually 
absorbed if asepsis has been good, but in 
a certain proportion of cases goes on to 
softening, to suppuration and to the for- 
mation of an abscess. It rarely or never 
disappears under two weeks, often persists 
for a longer time, as has been shown by 
Balzer at autopsies, and its disintegration 
is sometimes attended with extensive 
sloughing and cellulitis. 

Constitutionally, calomel injections have 
produced the following unfavorable results. 
Stomatitis, in spite of the assertions to the 
contrary, has not been infrequent, is often 
very persistent, and is sometimes of a very 
grave variety, attended with all the more 
dangerous phenomena of ptyalism. It is 
the more serious, as it comes on suddenly 
(fulminating type), and is very rebellious 
to ordinary treatment. This intract- 
ability is probably due to the continuous 
absorption going on from the poiut of 
deposit of the drug, and has in more than 
one instance neccessitated the excision of 
the indurated tissue thereabouts (Volger 
has reported three such cases), and the 
cauterization of the walls of the resulting 
wound. Gastro- enteritis and colitis have 



Vol. Ixix 

occurred (Besnier) and have even been 
fatal (Krans), and two cases of pneu- 
monia following a calomel and oil injec- 
tion have been reported (Klotz), and 
were presumably due to oil embolism. 

On the other hand, the influence of the 
drug thus used upon the symptoms of 
syphilis in the secondary stage^ and its 
occasional value as an adjuvant to the 
iodides in the treatment of later phe- 
nomena when grave or dangerous, have 
been abundantly demonstrated. The 
most striking results have been obtained 
in specific eye troubles, but various forms 
of visual and connective tissue lesions have 
been reported as rapidly cured by its use. 

There can be no reason to doubt its 
efficacy (if properly administered) during 
the secondary stage of syphilis. Mer- 
curialization, however produced, is then 
at its acme of usefulness. There is much 
more reason to question the reported bene- 
fits in all forms of tertiary syphilis. It is 
contrary to the accumulated experience of 
the profession to find, in late syphilis, that 
gummata, periosteal nodes, osteitis, tuber- 
cular syphilides and other phenomena of 
similar character yield promptly to the 
use of mercury alone. It is undoubtedly 
of value then as an adjuvant to or in con- 
junction with the iodides, but on both 
theoretical and clinical grounds cannot be 
expected to supersede them. 

Smirnoff's reported cases require con- 
firmation. Taylor acutely says :" Smir- 
noff siguiflcantly remarks that if, during 
a course of injections in tertiary syphilis, 
aggravation of the symptoms occurs, they 
should be stopped at once and the iodide 
of potassium should be substituted." 

One possible advantage of calomel may 
be properly mentioned here. Jullien (Ze 
Bulletin Medical^ June 19, 1892), calls 
attention to its diagnostic value in doubt- 
ful surgical cases : He says: "The pro- 
priety of operating in certain cases is, in 
the experience of every surgeon, counter- 
acted by uncertainty of diagnosis ; an ul- 
ceration, a tumor of ambiguous identity, 
makes one suspect cancer, without casting 
aside all waverings toward the side of syphi- 
lis. The surgeon should, in such a case, in- 
stitute a course of treatment to throw 
light as rapidly as possible on the obscure 
points. Under these conditions, Jullien 
says he cannot too vehemently proclaim 
the superiority of calomel injections used 
according to the Scarenzio-Smirnoff 

method : ^t grain (0.097 gramme) of cal- 
omel suspended in 15 grains (0.97 
gramme) of liquid vaselin, thoroughly 
sterilized, and injected once into the 
gluteal muscles under aseptic conditions. 
He says no one can deny the profound 
modification which it exercises upon a 
syphilitic neoplasm, no matter what has 
been its duration. In five cases which he 
cites he determined whether a tumor was 
a manifestation of syphilis or not, in short, 
whether or not operation was indicated. 
He adds : 

" Calomel by injection presents, in the 
highest degree, the qualifications of a test- 
medicine." He thinks that no argument 
can be brought up in opposition ; and that 
if the surgeon does not utilize this 
method, •'^it is not — it cannot be — that 
he condemns it, but that he is ignorant 
of it." It may be discarded in the 
methodic, prolonged treatment of 
syphilis; but all its inconveniences are 
obliterated by two indubitable facts in the 
presence of doubts concerning a malig- 
nant degeneration, where " delays are 
dangerous." These two facts are: "1.' 
That a therapeutic diagnosis of syphilis is 
clearly defined in eight days by injection 
of calomel. 2. In case of negative results, 
this treatment has not impeded the neces- 
sary operation in the slightest degree, and 
does not in the least complicate its re- 
sults. " However, even Jullien says that 
it must not be used blindly, and that it is 
best not to employ it in cases of marked 
albuminuria. If further experience con- 
firms these observations, it will be one of 
the best practical results following the ex- 
cessive (and unnecessary) use of hypoder- 
matic treatment which has been the 
fashion for some years on certain parts 
of the Continent. 

{h.) Metallic Mercury. The dose em- 
ployed has been from 5 to 20 or 30 grains 
once weekly, followed by kneading and 
rubbing of the region. 

(c.) Gray Oil {Oleum cinerium) is a 
form of metallic mercury which has been 
much more widely used. It is prepared 
by making an ointment or pomade of mer- 
cury with lanoline as a basis, and then 
diluting this with almond or olive oil 
(Lang), or by triturating metallic mer- 
cury with etheral tincture of benzoin and 
oil of vaseline (Neisser), or by combining 
with the mercury and lanoline a two per 
cent, carbolized olive oil (Althaus). 

July 22, 1893. 



[d). The yellow Oxide of Mercury. 
Taylor says that this salt is to-day the 
most generally nsed hypodermatically of 
all the mercurial compounds, having 
largely replaced calomel. The evidence as 
to their comparative value is not so con- 
flictingjas usual. The drug was introduced 
by Watrasewski, who gave up calomel on 
account of the pain and unpleasant symp- 
toms which it produces. His formula is : 

T>. Hydrarg. oxid. flav gr. xv 

XV Acaciae gr. iv 

Aquae destillat fgi.— M. 

He uses a Pravaz syringeful, and says 
that three to six injections suffice for a 
*'cure,'^ which Taylor says, "• it must 
always be remembered, means, in the 
minds of most exploiters of hypodermatic 
mercurial preparations in syphilis, the 
disappearance of a given set of symptoms 
or lesions." The following remarks of 
Taylor throw such a strong side light on 
this whole question of the hyodermatic 
treatment of syphilis that I quote them 
fully: ^' Tchernoguboff uses this pre- 
paration in doses of 2 grains every ten or 
eleven days, injected into the muscles. 
He says that syphilitic children from 12 
to 14 years old tolerate one-grain doses 
hypodermatically very well, and are bene- 
fited. He treated 120 cases, male, and 
female, young and old, without any un- 
toward complications. It is interesting to 
rem^ember that Lesser observed abdominal 
pains, vomiting, and bloody and mucoid 
diarrhoea after injections of yellow oxide, 
and never after calomel. The conclusion, 
therefore, is warranted that we can only 
get at the truth as regards the advantages 
and drawbacks peculiar to any and all 
preparations by the study of the experience 
of many men. It is never well to rely 
fully upon the assertions of the exploiter 
of a new mercurial preparation or com- 
bination. Thus we find that Dampekoff 
used the yellow oxide upon 179 syphilitic 
women, and that ^' neither intense pain 
nor suppuration was produced. " Yet these 
women absolutely refused to allow the 
continuation of the treatment by reason 
of the severity of the pain. Then, on 
the other hand, Eeshetnikoff, in the course 
of 1800 injections of yellow oxide, sus- 
pended in vaseline oil, jnade into the 
gluteal regions, never met with an instance 
of local suppuration, and only once saw 
a diffuse sanguinolent infiltration, which 
disappeared without any bad result," 

(e). The neutral salicylate of mercury. 

(/). Thymolate of mercury. 

{g.) The black oxide, protiodide, red 
oxide, tannate, sulphate, turpeth mineral 
and cinnabar have all been used. 

This does not begin to complete the 
formidable list of therapeutic suggestions 
that have been made, and, unfortunately 
for the patient, acted upon during the 
last few years. 

The positive objections to it I have al- 
ready sufficiently considered. Marked 
pain, sensitive nodosities, cellulitis, slough- 
ing and abscess, liability to disfiguring and 
permanent cicatrices, to a sudden and 
grave type of stomatitis, to violent entero- 
colitis, to pseudo-paralyses, albuminuria, 
pulmonary embolism, etc., even if they 
occur in but a small percentage of cases, 
make up a sufficiently formidable list of 
possible accidents to warrant a reasona- 
ble hesitation before giving up older and 
well-tried methods, practically free from 
danger, in favor of this one. 

The objections to it by the patients 
themselves are a serious obstacle, in this 
country at least, to the practical success of 
the method. Even our hospital and dis- 
pensary cases are a much more independ- 
ent class than the same sort of people 
abroad, and cannot be subjected to whole- 
sale experimentation with the same impu- 
nity. In Paris, Fournier has called at- 
tention to the fact that syphilitics flocked 
from the hospitals where this method was 
being tried to his service. In private 
practice here it would certainly be difficult 
of adoption, and while it might be attend- 
ed by the rapid disappearance of symp- 
toms, there would often be an equally 
rapid disappearance of patients. 

The figures which are gradually accu- 
mulating, tend already to show that its 
employment, according to current formu- 
Ise, brings with it another danger, viz., 
that involved in the encouragement of, in- 
sufficient treatment, in the dependence 
upon the short and heroic courses, which, 
as Hutchinson says, are often followed by 
the gravest and most serious tertiary phe- 

The claim that by a few injections the 
time of treatment can be measured in 
months, or even in weeks, instead of years, 
would seem, as Mauriac has said, to in- 
volve the idea that mercury given hypo- 
dermatically acquires some new and pow- 
erful curative property which, given in 



Vol. Ixix 

other ways, it does not possess. As 
matter of fact, when we inject the insol- 
uble salts, we are merely leaving the chem- 
istry of their transformation into the sol- 
uble compounds to the tissues themselves; 
when we inject the soluble salts we are 
sim*)ly reaching the general circulation by 
a somewhat more direct method than when 
we approach it through the capillaries and 
absorbents of the skin or the gastro-intes- 
tinal tract. 

I believe that, on the whole, while the 
final outcome of the experiences of the 
last few years will doubtless be for the ad- 
vantage of science and the extension of 
our therapeutic methods, the information 
thus acquired will be at the expense of 
many patients who will suffer from the 
direct consequences of the method itself 
or succumb to the ultimate development 
of insufficiently treated syphilis. 

In England, Hutchinson, who is, facile 
lyrincejps^ the leader of British syphilogra- 
phers (and who, in my opinion, is, with 
the possible exceiDtion of Fournier, the 
leading syphilograper of the world) says: 
'^Hypodermatic injection has come but 
little into employment in English prac- 
tice, nor does it appear to increase in favor 
with those Continental surgeons who at 
one time thought highest of it." 

In this country Taylor, so far as I know, 
voices the prevailing sentiment among 
specialists in this branch when he says: 
' ' The extent of the literature of hypoder- 
matic injections in syphilis contributed 
within the past ten or twelve years is sim- 
ply appalling, and there is really very lit- 
tle which is of practical value. It will be 
seen that almost every preparation of mer- 
cury has been experimented with in the 
hypodermatic injection treatment, and 
that the chemist's art has been sorely 
taxed to produce new preparations. Each 
new preparation has been exploited as the 
ideal of perfection, and in most cases a 
hearty welcome has been accorded it, so 
that a witty G-erman reviewer has made 
the following paraphrase of an old maxim 
applicable to the subject: 'He novis nil 
nisi bonum.' " 

As to the injection of insoluble prepa- 
rations, he says he has no leaning toward 
its employment, and that he is firmly con- 
vinced that it will never be used as a sys- 
tematic treatment extending over a jDeriod 
of years. He adds: "It is a treatment 
which is generally irksome and repulsive 

a to patients, always attended with more or 

less discomfort and pain, and often pro- 
ducing destructive subcutaneous lesions 
over the body, which cause mental and 
physical suffering, and which of necessity 
must impair the patient's health and 
strength. In some cases we have seen, it 
has been known to imperil and to destroy 

The soluble preparations he uses, as do 
most of us under various limitations. 

In the light of the evidence presented 
above, it seems to me safe to assert that: 
The hypodermatic treatment of syphilis 
has not as yet shown results which war- 
rant its adoption as a routine method to 
the exclusion of or in reference to other 
methods, but, on the contrary, has some 
apparently insuperable disadvantages and 
even dangers which render it improbable 
that it ever will be so adopted.' 

2. The circumstances under which 
hypodermatic medication should be em- 
ployed may be summarized as follows: a. 
Those cases in which other methods of 
treatment have been tried and failed, h. 
Those cases in which, owing to idiosyn- 
crasy or intercurrent disease, the skin and 
the digestive tract cannot be used for the 
introduction of mercury, c. Those cases 
in which, owing to grave and advancing 
lesions, rapid mercurialization is abso- 
lutely necessary, d. Those cases in which 
obstinate localized lesions can be most di- 
rectly reached by this plan. e. Possibly 
those cases in which early differentiation 
between syphilis and malignant disease, 
or tubercular ulceration, is extremely im- 
portant, should be included in this list. 
I certainly feel inclined to employ the 
method in all doubtful cases which admit 
of it, particularly in those conditions of 
the tongue which often leave the surgeon 
for a considerable time in doubt as to their 
exact nature. Anything which promises 
to shorten this period of doubt by render- 
ing the therapeutic test more rapid and 
more certain would be of great advantage. 
I should, however, in such instances feel 
obliged to use potassium iodide by the 
mouth at the same time. /. A theoreti- 
cal possibility of the employment of mer- 
cury hypodermatically has suggested itself 
to me, but I have not as yet actually em- 
2Dloyed it. It may be that its use by this 
method will aid in shortening the period 
of doubt which often intervenes between 
the appearance of the primary sore and 

July 22, 1893. 



the development of general adenopathy or 
of the exanthemata. If, in the presence 
of a sore of uncertain character, the em- 
ployment of mercury hypodermatically 
resulted in rapid cicatrization, no local 
treatment being employed other than 
cleanliness, it might occasionally throw 
light upon the case without being open 
to all the objections which attend the 
systematic and slower administration of 
mercury by the mouth. It is possible 
that the idea is worth a trial in excep- 
tional cases, but I do not think it should 
be adopted as "a routine practice, 

3. As to the choice between the two 
great classes of mercurials, the soluble 
salts are to be preferred to the insoluble 
in the large majority of cases, as more 
exact in the matter of dosage and much 
less dangerous and less likely to be fol- 
lowed by local disturbances. They are 
alv/ays to be used when there is need for 
rapid mercurialization. 

The insoluble salts should probably be 
reserved for those cases in which frequent 
visits to the surgeon are impossible and in 
which no contra-indications exist. In 
cases of defective kidneys, diabetes, pro- 
found anaemia, marked atheroma, great 
debility, etc., such methods are danger- 

ous, and the case, even if urgent, will 
probably do better under some other form 
of treatment. 

4. Finally, as to the special preparation 
to be employed : Among the soluble salts 
the bichloride is probably to be preferred. 
The results from its use are not strikingly 
different from those obtained from the 
other compounds of this class, but its 
stability and great solubility and its ger- 
micidal qualities seem to warrant its selec- 
tion. The disadvantage is the pain which 
it causes, but the evidence in this direction 
shows that in the hands of impartial 
investigators, not responsible for the in- 
troduction of the particular substance 
employed, each of the salts on the list 
produces a considerable amount of pain 
and a not inconsiderable number of 
accidents or complications. Probably the 
bichloride is freer from objectionable fea- 
tures, in respect especially to the produc- 
tion of suppuration, than any of the salts of 

Among the insoluble salts calomel and 
the yellow oxide are to be preferred. It 
would appear that the latter is a little less 
active, but at the same time much less 
irritating. Gray oil is the most available 
form of administering metallic mercury. 




CHARLES B. WILLIAMS * A. B., M. D., Philadelphia. 

F. M., aet. 43; white; married; was ad- 
mitted to the Pennsylvania Hospital on 
the afternoon of June 29, 1892, suffering 
with a compound dislocation of his left 
internal malleolus, the result of a fall 
from the third story of a building which 
he was painting. There Avas a large lacer- 
ated wound over the external malleolus (or 
the place where it is normaly situated, — for 
in this man the external malleolus, as well 
as the fourth toe with its accompanying 
metatarsal bone were congenitally absent) 
through which wound protruded a 
portion of the articulating surface of the 
astragalus. The foot was warm and the 

■••■Ex-resident physician Penna. Hospital ; Assistant 
surgeon to Methodist Episcopal Hospital. 

arteries intact. The patient was con- 
siderably shocked upon admission, temper- 
ature 99°, pulse soft and compressible. 
He was given hypodermics of strychninae 
sulph. gr. 1-40 with tr. digitalis m. x. be- 
fore the operation, as well as several 
hypodermics of ether and one of atropise 
sulph. gr. 1-120 during the operation. 

Operation, The patient was etherized, 
the wound slightly enlarged, and the 
astragalus severed from its attachments 
by means of a probe pointed knife, and 
then excised. In like manner, the internal 
malleolus was also removed. The articula- 
ting surface of the tibia was next sawed 
of. x\s the anterior and posterior tibial 
arteries were uninjured, only a few small 



Vol. Ixix 

veins required ligation. After a rubber 
drainage tube bad been inserted in the 
wound, its edges were united by means of 
silver wire sutures. The limb was dressed 
antiseptically and placed in a fracture box. 

The patient was now ordered ammon. 
carb. gr.v. every ^ hour, whiskey drs. ij. 
hourly, and tr. digitalis gtt. v. every four 
hours, the frequency of the doses to be 
diminished as soon as the patient re- 

At 9 P. M. there was considerable 
oozing through the dressings which ne- 
cessitated their being reinforced with 
bichloride cotton. 

June 30, 1892. Oozing from the wound 
has ceased. Limb is in good position. 
Patient complains of his back hurting 
him, for which warm leadwater and 
laudanum was ordered. Has no pain in 
his ankle. 

July 3, 1892. Limb dressed to-day. 
The edges of the wound appear to be well 
approximated. No discharge through the 
drainage tube, which was now shortened a 

July 13, 1892. Dressed yesterday. All 
of the silver sutures were removed. There 
was but little discharge. The tube was 
further shortened and the limb dressed as 
before. The position of the foot and 
ankle is excellent. 

August 13, 1892. The fracture-box 
dressing was discontinued to-day. There 
is scarcely any discharge from the wound 
now. There seems to be some slight mo- 
tion in the ankle-joint. In place of the 
fracture-box two lateral splints of Eus- 
sian felt, moulded accurately to fit the 
limb, were applied with a small antiseptic 
dressing, and the patient allowed to be up 
and about in a wheeled chair. 

August 16, 1892. Wound is entirely 
healed. The patient walks quite well with 
the aid of crutches. 

August 17, 1892. The patient went out 
on a pass to-day and eloped. 

September 7, 1892. The patient came 
back to the hospital to-day. He still uses 
crutches. There is some slight motion in 
the ankle-joint. The wound has entirely 
healed. The shortening amounts to about 
2-|- inches and the patient walks on the 
ball of his foot with the heel elevated. Or- 
dered to procure a shoe with a "■ built-up" 

The patient walked into the hospital 
about four months ago. He had aban- 

doned crutches and was wearing a shoe 
with only the heel "built up." Conse- 
quently he experienced considerable dis- 
comfort in walking and his ankle tired 
very easily. There was considerable mo- 
tian to be observed in the ankle now. The 
patient was ordered to have the sole of the 
shoe, as well as the heel, built up for 2^ 
inches and then to return and report to 
the hospital. This last request he has 
never obeyed. 

Aristol in Hemorrhoids. 

To establish a radical cure, all causes to be 
ascribed to a faulty diet strong drinks or 
want of exercise must first be removed, says 
Dr. Engle {Med. Summ). Then every morn- 
ing and night, and in severe cases every three 
or four hours, about one ounce of cold water 
is injected into the rectum and allowed to 
remain as long as possible. Morning and 
night the following supiDository is applied: 

T> Kxtracti opii grs. iij 

j^ Extract! belladonnae gr. j 

Quiniae muriat., grs. xxvj 

Aristol 5j 

Olei theobrom., 

Ceraealbae aa q. s. 

M. Et fiant suppossitoriaNo. vi. 
Sig.— One, morning and night. 

Immediately after each movement of the 
bowels the following salve spread over the 
point of the index finger is pushed up into 
the rectum for about one and a half inches, 
and some upward pressure is exerted by the 
external sphincter. 

T>, Unguent zinci benzoat Sj 

-i^ Balsam Peruvian 5j 

Aristol grs. xxx 

M. Ft. Ungt. 

Sig.— Externally . 

While, internally from one to two heaped 
teaspoonfuls, in plenty of water, are taken 
two or three times daily of the following pow- 

T>, Sulphur, flor., 

jpkJ Potass, bitartrat,, aa Sj 

Mt. Ft. pulvis. 

— Medical Review, 

For Pain in the Ear from inflammation, 
Dr. John Dunn (quoted in La Semaine Medi- 
cale) recommends the following: 


Menthol pulv.. 

Camphor, pulv. , aa gr. xx 

Vaseline liquid f Sj 

-Instill a few drops into the ears several times a 

For Vomiting after Etherization. 

Prof. Hare ( Coll. and Clin. Record) recom- 
mends the following: 

T> Tincturse opii deodoratse gtts. xxx 

Jpk? Sodii bromidi grs. xxx 

Aquseamyli Sij oriij 

M. Sig.— As an enema. 

July 22, 1893. 

Society Reports. 



Stated Meeting April IJi., 1893. 

The President, Dr. F. 0. Simpson, in 
the Chair. 


Dr. F. C. Wilson: This specimen is 
from a patient, male, aged about fifty- 
seven years, who had always been perfectly 
healthy, that is he had never been under 
a physician^s charge, although never 
robust in appearance. He commenced 
having some difficulty in swallowing which 
gradually increased to such extent that he 
became uneasy about it, and he began at 
the same time to vomit. He never had 
any very severe pain of any sort ; gave no 
history of having swallowed any poison or 
corrosive substance, and was of course at 
a loss to account for the trouble. When 
I saw him, I found that he was able to 
swallow liquids, but in an irregular way. 
Sometimes he would be able to swallow 
then for a day or two, at other times for 
some days he would hardly be able to get 
anything down. When anything would 
pass down, after a while a good deal of it 
would be regurgitated. He gradually grew 
worse until he was considerably emaciated. 
I .questioned him concerning his symptoms, 
as to the possible inheritance of cancerous 
trouble, as to his having swallowed any 
substance like a piece of bone, or any 
corrosive material, but found that he gave 
no history of anything of that nature. 
I could locate by auscultation some ob- 
struction during the act of swallowing 
near the lower end of the oesophagus ; I 
could hear it distinctly as he would swallow 
while I listened over the course of the 
oesophagus. I suggested to him that I 
explore the oesophagus, at the same time 
pass any obstruction that might be there 
by means of the bougie or feeding tube. 
During auscultation I listened carefully 
for evidence of aneurism or bruit thinking 
there might possibly be some obstruction 
due to that, but nothing of the sort could 
be heard. The patient complained of no 
pain such as we usually find in aneurism 
occurring in proximity to the vertebral 
column ; we know that gives rise to severe 
boring pain due to breaking down of these 

vertebrae by impact of the developing 
tumor. Nothing of the kind could be 
elicited in the history and there was no 
evidence of any aneurismal enlargement. 
I made an engagement with him and 
visited him for the purpose of introducing 
a tube. He was a very timid and nervous 
man and I had some difficulty in passing the 
tube, but I could distinctly recognize the 
obstruction when that point was reached. 
I succeeded in passing an ordinary rubber 
feeding tube and poured through it a 
fairly good meal of milk and after that 
for several days he was able to swallow 
with a great deal more ease. I made 
another engagement" with him for several 
days later, but before the time was reached 
he sent word that he was swallowing sc 
much better he believed he would post- 
pone it. I saw no more of him, and six 
months afterwards I saw notice of his 
death. He passed into the hands of some 
Homoeopathic physician; he grew grad- 
ually worse and more emaciated, and 
finally death occured from exhaustion. 
I was called to make a post mortem in the 
case. I made the autopsy and secured 
this specimen which I present here to-night 
with the idea of getting the opinion of 
the society as to the nature of the enlarge- 
ment. No microscopical examination has 
been made thus far. In making the post 
morten examination I opened the chest 
and found no trouble to account for death 
until I reached the oesophagus. I removed 
the entire mass, oesophagus and stomach, 
and in slitting open the oesophagus I found 
near the lower extremity some excrescence- 
like growths which involved the lower 
portioHT of the oesophagus and extended 
through the cardiac orifice into the 
stomach. This enlargement or growth 
looked very much like an excrescence, 
not nodulated and not hard. The stomach 
was very much contracted. There was 
no involvement of the neighboring organs, 
of the liver or spleen. I believe Dr. 
Coomes saw the case a number of times 
and passed the bougie,but what his opinion 
was as to the nature of the trouble, I am 
unable to say. One Homoeopathic physician 


Society Reports. 

Vol. Ixix 

who saw the patient, I think, made di- 
agonsis of aneurismal enlargement of the 
aorta. Nothing except a careful micro- 
scopical examination can clear up the exact 
nature of the case 


Dr. J. A. Larkabee: I have had quite 
a number of cases of stricture of the oesoph- 
agus, eight or ten probably, covering my 
experience in practice. I have one now that 
I would like to turn over to the Homoeo- 
paths. I think this is a capital idea. The 
patient referred to came to my office about 
two weeks ago ; I started in by passing an 
Oliver bougie^ smallest size. After three 
dilatations in that way I passed the larger 
one, which is the largest size of four 
bougies in the set manufactured by Oliver. 
I told him I thought that amount of 
dilatation would give him some relief and 
iully expected it to do so, whether it was 
temporary or otherwise, but contrary to 
my expectations,he reported that it was no 
better an hour afterward so far as swallow- 
ing was concerned than it was an hour 
before. I scraped some of the material 
from the tube after withdrawal and handed 
it to Dr. Vissman for examination. This 
patient is not emaciated and presents a 
very fair appearance. There is no can- 
cerous cachexia, neither has he a cancerous 
history. Now I believe this man is going 
the way of the other case of stricture of 
the oesaphagus reported, but just what the 
nature of the stricture is, I do not know. 
The case has only been under my observa- 
tion for two weeks, and he has been unable 
to swallow anything except fluids. Aus- 
cultation locates the obstruction about 
midway of the oesophagus, you can hear it 
" chuck ^' there just as plainly as you 
could a bucket, then the fluid slowly 
trickles down. 

Dr. a. M. Oartledge: It seems to me 
in cases of this character the first thing to 
establish is "stricture of the oesophagus" 
after that fact has once been established 
usually there is but little difficulty in 
determining the nature. Certainly there 
should be very little trouble after death 
has taken place. It seems to me differ- 
entiation should be very easy. True ste- 
nosis of the oesophagus is cicatrical or 
malignant. Cicatrical stenosis is the 
result of syphilitic ulceration, more rarely 
tuberculous and very commonly the result 
of trauma. 

In the case reported by Dr. Wilson, 

without a microscopical examination I do 
not think anyone should pass a judgment, 
but my opinion is that it is clearly malignant 
disease. It is not sypilitic, it is not tuber- 
culous, and I take it from the size of the 
deposit and the macroscopical appearance 
that it is carcinoma, and believe that the 
microscope will prove it. 

Dr. J. A. Larrabee : A¥ould it be pos- 
sible if it were carcinoma without any ul- 
cerative stage set up, to have told from the 
secretions whether it was cancer or not ? 

Dr. Wm. Vissmak (Visiting) : I do not 
think there is any possible way of telling 
whether it is cancerous or tuberculous, or 
anything else, unless you get a particle of 
the tumor, and you could not get this 
without there was a breaking down. 

Concerning the specimen exhibited by 
Dr. Wilson: From a macroscopical ex- 
amination I think there is no doubt about 
its being a carcinoma. One peculiarity 
about the tumor is that we cannot dis- 
cover the exact line of the stomach, that 
is where the stomach has been taken off. 
Another peculiarity is that carcinoma of 
the oesophagus very seldom or never, we 
might say, extends into the stomach. It 
may be that the microscope will shovv that 
this is nothing more nor less than a car- 
cinoma of the oesophagus. 

Dr. F. C. Wilson: I had mapped out 
a plan of management of the case which 
possibly may have had something to do 
with scaring him off. I had spoken 
either to the patient himself or a friend of 
the advisability of feeding him in the way 
that I had attempted to do, and if that 
failed then of putting a tube into the 
stomach from the outside so that he 
might be fed in that way. Of course, if 
the tumor proves to be malignant in char- 
acter, it would eventually have caused 
death, but I believe his life might have 
been prolonged by the insertion of a tube 
into the stomach. He was greatly ema- 
ciated, and certainly died from sheer ex- 
haustion. Had the tube been inserted in 
the stomach from the outside, his life 
might have been prolonged possibly 
several months at least. 

Note : A subsequent microscopical ex- 
amination of the specimen by Dr. Viss- 
man clearly proves the trouble to have 
been of a cancerous nature. 

Cornelius Skinner, M.D., then read a 
paper on 


July 22, 1893. 

Society Reports. 


Of all minor troubles to which the at- 
tention of the practitioner is called, I am 
persuaded that constipation is the most 
common and, I am equally bold to say, 
the most intractable in its cure. It is my 
purpose in this short paper not to treat of 
constipation in all of its forms, but to 
take up that one in which constipation 
seems to be the disease and not the symp- 
tom. Stricture, fissure, hemorrhoids, spi- 
nal lesions, tumors, etc., will not be spok- 
en of, but rather that form in which we 
find tardy and difficult defecation, with 
hard, scibalous stools. We will not use the 
time in rehashing the symptoms and ef- 
fects in general, but go direct to the form 
in question. 

A large majority of these patients we 
find among the women, and most usually 
from 15 to 30' years of age. The usual 
chain of symptoms are given and, on cas- 
ual questioning, we find that they have 
had time for and paid more attention to 
everything else in life than to the bowels. 
They are punctilious in all engagements, 
regular at meals, etc. , but not at stools. 
The most trivial affairs, social and other- 
wise, causing a postponement of one of 
the most important calls of nature to a 
more convenient season, which is usually 
the next day. Again, we find not all 
typewriters, teachers, etc., or people who 
lead a sedentary life, but just as often 
floor-walkers, postmen, or those who take 
a good deal of exercise, with good diges- 
tions and appetites sufficient. One thing 
is noticed in, I might say, all of this class, 
and I consider it the prime cause of all 
trouble, viz: These people do not drink 
a sufficient quantity in twenty-four hours 
for nature^s demands. They are notice- 
ably small drinkers, and never take water 
unless prompted by thirst or at meals, and 
then will drink to excess. The majority 
of people in general drink too much while 
eating, thus diluting the juices of diges- 
tion to a degree which will eventually im- 
pair digestion. It is not easy for us to 
realize the amount of water thrown off by 
a healthy man or woman in twenty-four 
hours : 

By the kidn eys we lose 42 oun ces. 

By the lungs we lose 23 ounces. 

By the skin we lose 15 ounces. 

Now contrast this with the amount 
taken in during the same time, and we 
find little enough left for the bowels un- 
der most favorable conditions, and when 

we lessen this by one-fourth or one-half, 
we find nothing left to keep the stools 
soft and in the proper condition to be, by 
peristalsis, packed down into the sigmoid, 
ready for prompt and easy expulsion. 

Constipation may be called the machine 
of "perpetual motion;^' for, when once 
started, it perpetuates itself until checked 
by proper causes. Now I admit that we 
must find the cause for all things, and 
then remove that cause in order to effect a 
cure; and, in this very common form just 
spoken of, to relieve it, we have simply to 
furnish that deficiency of water in the 
proper way, and the cure is effected. 

It is my custom not to employ any of 
the waters now sold for constipation ; first, 
because they will not cure, but establish 
in the bowel that habit which we want to 
avoid, of waiting to be driven into action 
by laxatives; secondly, they are expen- 

As I have said before, this water should 
not be taken at meals, nor too close to the 
meal hour, but long enough before in 
order that it may have time by absorption 
and otherwise to pass out of the stomach 
into the circulation and bowels below. I 
have the patients to drink an ordinary 
tumbler full of cold water thirty minutes 
before breakfast, dinner and supper, and to 
take the fourth at retiring, giving sixteen 
ounces or one pint in addition to that taken 
at meals as coffee, milk or tea, and during 
the day when thirsty. Except in very 
obstinate cases' this simple remedy gives 
me most gratifying results. In those in- 
tractable cases I generally use a little 
pill of aloes, belladonna, strychnia and 
podophyllin each night or less frequently 
during the week as the exigencies of the 
case require. There will be failures on 
the part of the water and much disap- 
pointment to a few patients who put 
their trust in this remedy, but if this plan 
is followed systematically m from two to 
six weeks we will get good results. As an 
apparent exception I wish to mention a 
case of constipation that has given me no 
little concern in. the past three weeks. 

Patient a tall, slender woman, raised in 
the country, of good health and family 
history; age thirty-nine years; married 
about two years; baby five months old. 
This woman first consulted me in the 
beginning of gestation for nausea and a 
small tumor in the left groin just about 
the site of inguinal hernia. No positive 


Society Reports. 

Vol. Ixix 

diagnosis of tumor was made, but I as- 
sured her that it would play no part in 
her confinement, and advised leaving it 
alone, there being no pain or other symp- 
toms to attract attention. Constipation was 
quite a factor during gestation, and re- 
mained so afterwards, but was tolerably well 
controlled by the water treatment with the 
addition of a small glass of Hunyadi water 
before breakfast. On the night of March 
21st I was called and found her suffering 
intense pain just over the symphysis and 
tumor mentioned ; pain did not intermit 
but was continuous ; tumor very sensitive 
to touch, almost constant nausea. My 
first impression was strangulated hernia; 
bowels had moved in the morning after 
the water was taken; pain began at five 
P. M. and this was eleven P. M. Usual 
domestic remedies had no effect; pulse 
95° ; temperature 98^° F. After watching 
the pain for an hour and still hesitating 
between strangulated hernia and colic, 
and realizing the importance of a positive 
dicision, I called Dr. Eodman in con- 
sultation. The Doctor meeting me in one 
hour, pain in the meantime had shifted 
into the epigastric region and had become 
much less. This changed the aspect 
somewhat, and we both concurred in its 
not beiag strangulation but colic. We 
concluded our visit at three A. M., but 
left a hypodermatic of morphia and 
atropia to be given by the husband if the 
pain grew worse. I saw the patient next 
morning at nine o'clock. She was com- 
fortable, but much nauseated ; pulse 75, 
temperature 98^° F. Nausea lasted all 
day and following night. On the morn- 
ing of the 23d still great nausea; pulse 
100, temperature normal; hot water or- 
dered, which controlled nausea. Met Dr. 
Rodman on the street, and we agreed to 
give calomel in one-grain doses until bow- 
els were moved or six grains had been 
taken. At 2 P. M., palse 110, tempera- 
ture normal; patient very restless and 
slightly flighty ; calomel was begun. Dr. 
Rodman saw her with me at 10.30 P. M. 
Pulse 120, temperature normal; restless- 
ness increased, with very marked flighti- 
ness ; no move from bowels. We now be- 
lieved that there was some internal obstruc- 
tion, and so expressed ourselves to the 
husband and, at the same time decided 
to open the abdomen in the early morn- 
ing if there was no change for the better. 
This he very positively sat upon, because 

her mother, living in the country, was not 
here to counsel. However, we felt that 
all responsibility had been assumed by 
the husband. 

Expecting to find the patient worse by 
morning, we left ; but with the determina- 
tion of going back early and prepared to 
operate at once. Drs. Mathews, Cecil and 
Bullock were asked to meet us ; we met at 
eight A.M. 24th, to find pulse 100, a drop 
of 20, temperature 98^° F., no restless- 
ness, and patient much better. Since the 
mother could not reach the city before 
seven P. M., we all decided to wait. 
Patient held her own until the 30th, when 
nausea again appeared with pulse 120 and 
temperature 99|-° F. Calomel was given in 
doses of one grain every hour for six hours 
but with no effect. On the afternoon of 
the first instant, castor oil in capsules 
one drachm each, was given every two hours 
to be kept up until bowels moved, or eight 
were given; after twelve hours bowels 
moved copiously and thus ended to us a 
most puzzling case. 

I will say that frequent colon irrigations 
were made by myself, with and without 

The point I want to make in the paper 
is, in this class of cases where we find no 
especial reason for the constipation, water 
given in the manner as described will 
result in a cure in most of them. The 
results of this treatment in my practice 
have been most gratifying. • 


Dr. J. A. Larrabee: I do not think a 
paper as interesting and instructive as the 
one presented by Dr. Skinner ought to go 
without remarks. I will say that when I 
received notification of this meeting and 
saw the name *' Constipation" as the sub- 
ject of the essay, I felt ^' bound " to come. 
The importance of what Dr. Skinner has 
said in regard to a "minor" condition 
becomes in the mind of every practitioner 
a '^ major" condition. The importance 
attached to the movements of the bowels 
may be best estimated by the love of peo- 
ple for cathartics. All a man has to do 
to make his fortune is to get up a cathar- 
tic pill or a powder for the same purpose. 
The desire of the community to be purged 
amounts almost to insanity. I do not 
suppose there is a board fence this side of 
Bullitt County that has not painted upon 
it something for regulating the bowels. 
There is not a peak in the Rocky Mount- 

July 22, 1893. 

Society Reports. 


ains so high that somebody has not 
climbed np to put Vinegar Bitters or Car- 
ter's Liver Pills on it, so you can judge 
somewhat of the importance attached to 
purgative medicines. Regulating the sys- 
tem and keeping the bowels in a soluble 
condition cannot be over-estimated, and I 
am one of those who believe in the poison- 
ous effects of retained material in the 
bowels; if we have a disease called 
" Uremia " from retention of the urine, I 
do not see why we cannot have diseases 
dependent upon " stercoraemia. " Many 
people may have died from causes pro- 
duced entirely by constipation. 

There is one point which has struck me 
all along while engaged in the practice of 
medicine, and that is the success of 
Quacks who use nothing else than aloin 
purificata in the treatment of chronic dis- 
eases. You can take it for granted that 
when a man starts out with patent medi- 
cines, medicines which he himself has 
patented and advertises for the cure 
of chronic diseases, that he is giving 
aloetic purgatives, and another fact that is 
not sufficiently weighed by physicians in 
debarring the Quack is that he succeeds 
in relieving many of these chronic cases. 
Any old chronic case of anything, I do not 
care what it is, whether rheumatism, gout 
or whatever it may be, is more or less re- 
lieved by a severe purging. That is 
where the Quacks get in their work, they 
help every case of that nature, old pa- 
tients, men who have been drinking a 
good deal. I know of half a dozen cases 
here where old chronic cases of mine have 
brought medicines from men who were 
selling them along the street, *the vilest 
compound ever put up, a decoction of 
aloes and horse aloes at that, and every 
one of them were relieved, and relieved 
for quite a while. I speak of this, gentle- 
men, just to call attention again to these 
forgotten facts of our law, where we fail 
in the course of treatment to secure free 
daily alvine dejections. We can adminis- 
ter a tonic, we can administer iron, tonics 
for anaemia, spanaemia or hydraemia and 
the iron does very little good ; we do not 
get the reddened blood corpuscles, nor do 
we get the characteristic effects of the 
iron. In this particular the iron waters 
do more good than our iron simply be- 
cause they combine purgative salts with 
the iron. It was the custom of the old 
school to purge, to vomit, and to bleed ; 

this was the circle of therapeutics around 
which they moved, and certainly they 
were on the right track so far as purga- 
tion, dieting, etc. were concerned. I 
think we are forgetting a great deal of the 
dietary system, and our patients would 
probably be better off if the old regime 
were adhered to a little more closely. For 
instance, • I see- every day cathartics 
ordered, of different kinds, chologogues, 
etc., and the patient allowed to eat what 
he pleases; the old style was to make corn 
meal gruel, or oat meal gruel and while 
the patient was being purged he had to 
take this kind of a diet. Nothing has 
been said about the idea that constipation 
is dependent upon the rapid absorption of 
water from the intestinal tract. The 
rectum is a drying machine if it is any- 
thing, and so situated as to prevent our 
becoming nuisances to ourselves, taking 
up the water from the rectum and drying 
the feces in the proper shape. - ISFow those 
people who are constipated have very 
rapid absorption of water, unless you force 
large quantities upon them, which means 
certain cure; it need not be water laden 
with medicinal elements, simply water 
(being sure that it is fresh) and use it '^on 
account of its being water,^' preventing 
this rapid absorption and allow the feces 
to be liquid. 

The case reported by Dr. Skinner is an 
exceedingly instructive one, and one which 
comes up every now and then in practice. 
The Doctor has said very properly that it 
is a most puzzling case to present. For 
some reason we always think the worst 
about our patients ; we are apt to think of 
appendicitis, then of colic, then of intus- 
susception, etc. ; and in this case there 
seems to have been about this line of symp- 
toms. Yet it was evidently a case of tor- 
pidity of the bowels, with no great accu- 
mulation of fecal matter. 

Eeferring to Dr. Skinner^s statement 
that many of these cases take sufficient 
exercise. This is not in accord with my 
observations of chronic constipation, I 
believe that the caecum is so constructed, 
whether it is the design of nature to do 
this or not, that walking exercise has an 
effect like rubbing the caecum, on account 
of the muscles which pass behind it. The 
caecum is moved when a person is walking, 
which is not the case by any other means, 
except possibly riding a bicycle ; and this 
point I understand is to be brought out 


Society Reports. 

Vol. Ixix 

later in this society, as a committee has 
been appointed to make some investiga- 
tions in that direction. 

Now as to medicinal agents. We all 
know that purgatives, given per se, are 
injurious in a case of this kind. They 
call upon the peristaltic action of the bow- 
els ; and every time this is called upon the 
natural power of peristalsis in the bowel 
is lessened. Consequently, the more pur- 
gatives a person takes the more he must 
take, and all of them after a while lose 
their effect. In those cases where medica- 
tion becomes necessary, I believe it is far 
more sensible to administer an agent 
which shall paralyze the inhibitory nerv- 
ous supply and stimulate the sympathetic 
nervous supply. For this purpose I do 
not think there is anything equal to bella- 
donna and strychnine. The ^' little pill" 
of belladonna, aloine and strychnine I be- 
lieve to be the best known combination. 
These are agents which do the work of 
paralyzing, and I believe, in these cases, if 
morphine and atropine were given hypo- 
dermatically, you would have the desired 
effect without calomel. The check on the 
pneumogastric nerve as it is distributed to 
the bowel is lessened by belladonna; it 
paralyzes that nerve, allowing the feces to 
become free. I do not think we have, in 
the list of medicines, an agent which will do 
the work that belladonna does in this par- 
ticular; not belladonna alone, but all its 
congeneric mydriatics, and all the mydri- 
atics, act in the same way if we add to 
them strychnine, which possesses in itself 
a tonicity for the bowels. 

I have seen several cass of chronic con- 
stipation in infants. In these cases I have 
found that rubbing or kneeding the bowels 
with the hands for five or ten minutes 
produces an alvine dejection. We want 
of course to increase the tone of the bowels 
but I would urge the use of simply large 
quantities of water as this alone will usually 
produce catharsis. 

Dr. D. T. Smith : The subject up for 
dicussion as stated by the previous speaker 
is regarded as one of special importance. 
Dr. Skinner has narrowed the discussion 
very much by limiting it to functional 
constipation. The case reported by him 
may or may not have an application as 
illustrating a principle ; I rather think it 
has not. It may be more reasonable to 
suppose that there is an adhesion at some 
point in the colon in the case of his patient 

and the peristalsis arising at that point 
after narrowing might be sufficient ta 
cause that condition. We very frequently 
find that. However we do not often ob- 
serve vomiting in cases of funtional ob- 
struction. There is sometimes paralysis 
or peritonitis of that small portion of 
the intestine, which might be sufficient 
to cause ! death. I think from the 
history that the trouble is simply an 
adhesion causing a narrowing of the 
intestine or an arrest of peristalsis at 
same point. 

Concerning the treatment of constipa- 
tion : As this is a condition which is 
usually suspected to arise from an accumu- 
lation or obstruction of material that ought 
to have passed out with the fecal dis- 
charges, the most important thing is ta 
relieve the patient of this obstruction and 
then administer remedies which are known 
to have a stimulating effect upon the 

I reported before this society sometime 
ago, a case which Dr. Roberts saw with me, 
in which preparations were not exactly 
made, nevertheless everything was gotten 
in readiness to do an exploratory 
laparotomy for the relief of constipation. 
There was stercoraceous vomiting and other 
symptoms of obstruction. However, be- 
fore the time to operate, we gave the 
patient a pint of sweet oil, knowing it to 
to be a safe remedy in any attack, and the 
result was an almost immediate dis- 
appearance of the distressing symptoms, 
the patient recovered and is in fine health 
to-day. In this case there was retroversion 
of the uterus, some post-pelvic peritonitis 
and evidence of adhesions which probably 
accounted for the trouble. 

As Dr. Larrabee has said, the two 
remedies most relied upon in the treat- 
ment of constipation, as they do not irri- 
tate, are belladonna and strychnine, be- 
cause they stimulate the muscular coat of 
the bowel, and by stimulating its action 
developing a strength that overcomes the 
atonic condition. As far back as 1861, I 
know that belladonna, nux vomica and 
compound extract of colocynth were given 
in this way. Aloes act as a stimulant in 
a similar way. 

In regard to the use of water : There 
are two respects in which water will be 
beneficial. In the morning when we rise 
(with those of us who are subject to an 
accumulation of mucus in the lungs and 

July 22, 1893. 

Society Reports. 


stomach) the whole alimentary canal is 
covered with mucus accumulated during 
the night, and water taken early and 
freely will reach the lower bowel without 
being absorbed. Ordinarily there is an 
abundance of water passing into the blood 
and then back into the large bowel 
because we know a considerable number 
of substances are carried into the circula- 
tion and then back again through the 
large intestine, not reaching the small 
intestine. Therefore, about the only way 
to have water reach the small intestine 
unabsorbed is by taking it in the early 
morning. I find many patients unable to 
take more than a glassful immediately on 
rising owing to the nausea produced, and 
it becomes necessary for them to wait for 
a few minutes until this feeling passes off 
before taking a second glass. I direct 
them to take three or four glasses, if they 
find it necessary, or if less fails to do the 
work, until a sufficient quantity of water 
is taken before breakfast to secure an 
action on the bowels shortly afterward. I 
think one of the most important things 
in this connection is that we should have 
a certain time for evacuation each day. 
The absence of a fixed period for an effort 
at stool may be the cause of the trouble in 
many of these cases. Any person not 
giving the bowels opportunity to act at a 
given time will necessarily become consti- 
pated, even if the alimentary canal is in a 
healthy condition; then I think it is not a 
bad plan for awhile to induce excessive or 
over- action. 

I believe if proper attention were given 
to the matter of having a regular period 
for evacuation of the bowels, and patients 
instructed to drink water in the early 
morning, and a sufficient amount later in 
the day, that the administration of 
cathartics could be done away with to a 
great extent. I am aware while I am 
saying this that there are a great many 
people who cannot drink water, cases of 
of gouty diathesis, etc. , and for this class 
of people salines can be given which will 
carry the water through the stomach, 
which otherwise could not be done. 

Dr. F. 0. WiLsoiq-: I have been in the 
habit of using hot as well as cold water. 
Hot water is not quite as pleasant perhaps, 
but with the addition of a little lemon 
juice or salt it becomes really palatable 
and patients get very fond of it. I 
believe hot water preferable to cold, as it 

reduces the supply of blood in the capil- 
laries of the walls of the stomach, which 
thus warmed up is driven directly through 
the liver, through the pancreas and neigh- 
boring organs, stimulating them to in- 
creased activity, and we have necessarily 
increased supply of bile. On the other 
hand it increases the digestive fluid supply, 
not only in the stomach itself but in the 
pancreas, so that digestion is improved 
and at the same time peristaltic action is 

Dr. J. G-. Cecil: I have listened with 
a great deal of interest to the excellent 
paper read by Dr. Skinner, and to those 
who have already spoken. I fully agree 
that the subject of constipation cannot be 
too freely discussed, as it is a matter of 
very considerable importance. If I am a 
^'routinist" in anything it is in giving 
purgatives, and I very seldom undertake 
the treatment of a case of any kind with- 
out very carefully inquiring into the con- 
dition of the bowels and generally find 
that a purgative is demanded, and usually 
also find that all medicines as Dr. Larrabee 
has very properly said, are increased in 
their efficiency, by having the alimentary 
canal cleared out before their administra- 
tion, I have for a long time been very much 
of the same opinion as the essayist with 
regard to the administration of water and 
have often recommended it. I believe that 
the beneficial effects derived from many of 
the mineral springs which are visited owing 
to their advertised efficiency for constipa- 
tion, depend largely perhaps, upon the 
water taken because it is water and not so 
much from the fact that it contains medi- 
cinal properties ; quite so much also upon 
the quantity and regularity with which it 
is taken. 

Concerning the point raised by Dr. 
Larrabee in regard to constipation in 
infants : This is a matter that has caused 
me a great deal of trouble in my practice. 
Very frequently infants nursing or. feeding 
upon the bottle, become obstinately consti- 
pated and I have recently been in the habit 
of advising that the children be given 
watpr. I think this is a point that is often 
overlooked in the treatment of children, 
the mother or nurse naturally assuming 
that the infant gets sufficient quantity of 
water in the milk. I believe constipation 
in many of them ig very agreeably affected 
and frequently cured by the administration 
of water. 


Society Reports, 

Vol. Mx 

The case reported by Dr. Skinner is one 
of extreme interest; the history shows 
that this woman was nearing a point 
where surgical interference was urgently 
demanded. However, at the first visit I 
made (having seen the patient after she 
had been constipated several days, and 
after large quantities of purgative medi- 
cines had been given, after she had had 
injections also and with the history of the 
case given before I saw her), I was led to 
suspect a very different condition from 
what I really found ; the patient was in a 
fairly good condition, not particularly 
anxious in expression, not restless, not 
tympanitic, no fever, no tenderness, fairly 
good pulse, and thoroughly rational ; and 
under the most careful and searching ex- 
amination, I was unable to locate any 
tender spot or tumor in the abdominal 
cavity or any accumulation of fecal mat- 
ter. The hernia or whatever it was in 
the inguinal region to my mind had no 
bearing upon the case. I think if there 
had been an adhesion or stricture of the 
bowel at any point, as hinted at by Dr. 
Smith, we would have had a different line 
of symptoms from those present. T would 
hardly have expected to have seen an 
amelioration of symptoms without |)erfect 
relief, and I would have certainly expected 
to find an accumulation of fecal matter 
above this constriction, which we could 
not locate. I do not think I remember to 
have ever seen a case that resisted such 
heroic doses of purgative medicines as this 
woman did. Probably a week after my 
first visit Dr. Skinner met me on the 
street and told me that she was still con- 
stipated ; he had tried injections and flush- 
ing the bowels (Dr. Mathews' suggestion), 
which I am sure was followed out with a 
thoroughness not often practiced^, as Dr. 
Skinner did the work himself, and had 
there been simply an ordinary constipation 
of the lower bowel^ I am satisfied this 
treatment would have solved the problem. 
But as already indicated, there was no ef- 
fect. She was benefitted by the amount 
of water used in these injections, as I 
understand several were retained. To 
my mind there is no cause assignable for 
the obstinate constipation in this case, 
other than torpidity of the liver and 
bowels. Possibly there might have been 
temporary paresis of the small bowel ; the 
constipation I am satisfied was in the 
small bowel. 

De. T. S. Bullock: I only want to 

speak of the manner in which the flushing 
was done in this case: It was done 
through a rectal tube passed to the sig- 
moid flexure, a copious amount of fluid 
being used as already indicated, and if 
there had been an accumulation of fecal 
matter in the larger bowel, and I am in- 
clined to think that it would have been 
very promptly removed by these repeated 
large amounts of water. Only a very 
small quantity of hard fecal matter was 
brought away by the injections. 

De. W. Oaeeoll Chapmai^ (visiting) : 
I would like to mention one point in this 
connection, which seems to me to come 
under the head of functional causes of 
constipation, especially in women, and 
that is lack of effort, which is often due, 
I find, to pain due to congestion and the 
attending sensitiveness in the genital 
organs — the ovaries, uterus or vagina. I 
have often seen women who were not 
constipated so far as desire goes, but com- 
plained that when they wanted to have 
stools they could not do so, excepting the 
effort caused them so much pain that they 
would not make sufficient effort to pro- 
duce an evacuation. It seems to me 
where this is the case, and I am satisfied 
that in women it does occur frequently, 
we should by hot injections or special ap- 
plications, as may seem best, endeavor to 
relieve this condition which would doubt- 
less relieve or possibly entirely cure the 

De. J. A. Laeeabee: The element of 
colic has been alluded to, which was en- 
tirely overlooked by me in my former re- 
marks concerning Dr. Skinner's case. 
How are we to determine that it was 
colic ? One feature of one kind of con- 
stipation that ought to be alluded to is 
that caused not by paralysis but by con- 
striction. For example take a case of 
lead colic, if you please, a case in which 
you have a portion of the intestines 
ligated by a circle of fibrous material with 
extreme pain. What kind of a purgative 
would you give there ? Certainly any 
effort to increase the peristaltic action 
would increase the trouble. Under these 
circumstances I believe that large doses of 
opium will produce an action from the 
bowels, an agent which it is well known 
will produce constipation. But under 
these conditions an action is produced 
upon purely scientific principles, it 
paralyzes the circular fibres. Whenever I 
see a case of lead colic and obtain that 

July 22, 1893. 

Society Reports. 


history, (I usually find that the patient 
has already taken large quantities of 
purgative medicines without effect) I ad- 
minister large doses of opium and it has 
been my experience that relief follows. 
Instead of paresis we can have an oposite 
condition of constriction by the circular 

Dr. D. T. Smith: I intended in my 
former remarks to refer to Dr. Larrabee's 
statement as to the way in which bella- 
donna affects the bowel. I believe that 
the doctor claimed that the good effects 
of this drug were produced by removing 
inhibition. I have never heard of any 
teaching that belladonna acts in this way. 
There are no ganglia situated in the walls 
of the intestines stimulating their action, 
as there are in the heart. Belladonna we 
know, acts doubly upon the heart; acts 
directly upon the heart muscles, at least, 
acts by inhibition of the motor centers 
from its own ganglia. 

I believe that the increased peristalsis 
is due to direct paralysis, not to an inhibi- 
tory one, as the doctor claims. 

De. J. A. Larrabee: All experiments 
upon the subject of belladonna which 
have been conducted by vivisection and 
otherwise, have shown that this above all 
other drugs places the intestines in peri- 
staltic action. Wherever there is a 
branch of the inhibitory nerve, belladonna 
acts, no matter whether by the capillaries, 
heart, liver or otherwise; wherever inhi- 
bition goes, there stimulation goes, and 
both go to every part of the economy. 
Every action of the body is controlled 
by two forces, like driving a horse with 
two reins; between the two you get a 
rhythmical action, but when one or the 
other is crossed, a different result is ob- 
tained. Of course the effect of bella- 
donna is through its action on the 
pneumogastric nerve. The benefit is de- 
rived by taking off the power of checking. 

Dr. 0. SKiiq-^ER: Concerning the ad- 
ministration of morphine in the case 
referred to in the paper: We all thought, 
after it had been given, that we ought not to 
have left the hypodermic injection there. 
If I had left the atropia without the mor- 
phine, I think it would have been better, 
as the morphia was undoubtedly the cause 
of the marked symptoms the second day. 
I believe it is a great mistake to give a 
hypodermatic of morphine when you want 
to make a differential diagnosis in such 

As to constipation in infants: Water 
can be administered in these cases with 
good results just as with adults. Mothers 
and nurses all tell you that the baby will 
not take water. That may be true, but 
the reason is that they have never been 
taught to take it. After a little persever- 
ance on the part of nurses the baby will of 
course take a sufficient amount of water to 
obtain the desired result. 

As to massage : That was not mentioned 
in the paper, I referred simply to the water 

I agree with Dr. Smith that having a 
stated time for evacuation of the bowels is 
an important factor. There is one thing 
above all others that a physician will 
observe in the treatment of constipation, 
and that is the little attention that these 
people give to periodical movements of the 
bowels. One reason why it is so common 
in women is that on account of their false 
modesty, or, for various reasons, they do 
not attend to this call of nature as they 
should. In this way constipation is 
started and then keeps itself up. 

Eeferring to Dr. Wilson's remarks in 
regard to his preference for hot water : I 
use cold water because I think patients 
will take more of it, and it is easier to take. 
In this special class of cases where we have 
young women from fifteen to thirty years 
of age to deal with, they will not take hot 
water. In older people probably hot water 
is more preferable. 

Dr. Chapman nientioned one very im- 
portant thing in reference to constipation 
in women, that is, pain produced by any 
effort at stool; for instance a displaced 
ovary may render defecation v.ery painful, 
especially if the feces have become hard, 
the pressure upon the prolapsed ovary will 
produce such pain that the patient is 
unable to make the necessary effort at 
stool. The majority of these cases are 
usually controlled by divulsion; you can 
take a case of this character and dilate 
the sphincter, after a short time relief will 
usually follow. 

Dr. Bullock spoke of the injections in the 
case reported by me. I know that these in- 
jections were very carefully given, and were 
really irrigations. I used a No. 7 tube its 
full length. In the first or second infection 
probably an ounce of fecal matter came 
away, after this nothing was returned ex- 
cept the injected water ; for that reason 
we believe that the trouble was not in the 
large intestine^ but a torpid small bowel. 

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Saturday, July 22nd, 1893. 



Most members of the profession cart 
remember when the relation of bacteria to 
wound infection was a mere hypothesis 
conceivable from a priori considerations 
but supported by comparatively few crudely 
made and half studied observations and 
vulnerable at every point to the keen, 
critical scrutiny to which every propo- 
sition is subjected. When in the unremit- 
ting search after truth, scientists put it to 
the test of practical utility this hypothesis 
deepened into conviction. Clinicians began 
to teach the theory of sepsis and the tech- 
nique of antisepsis, at first tentatively but 
with increasing confidence until at length 
with the full assurance that the microscopic 
objects which they could demonstrate, 
cultivate, transplant by inoculation and 
again collect, were the tangible causes of 
suppuration and septic complications. 

In 1886-7 Donald McLean, then of 
the University of Michigan, was almost 
the only operator who dared per- 
form coeliotomies in the public clinic. 
Two years later, Dr. Groodell tried the 

same experiment in the Hospital of the 
University of Pennsylvania and considered 
himself justified by the results. The 
standard antiseptic dressing in most Phila- 
delphia clinics at that time consisted of 
layer after layer of wet bichloride gauze, 
while the light, dry dressing was condemned 
on the ground that it did not adhere to 
the skin tightly enough to prevent the 
insinuation of germs beneath it. The 
fact was entirely overlooked that the 
most favorable results were achieved with 
the dry dressings and that the heavy, wet 
bichloride pack, like a poultice, softened 
the underlying tissues and provided one 
of the three requisites for septic fermenta- 
tion — moisture. 

It is unnecessary to allude to the 
inevitable " modification ^' by the ubi- 
quitous parasite of genius who bores 
for notoriety, or to the succession of 
chemicals that have been in vogue for 
longer or shorter periods. Antisepsis, in 
lessening the death rate, in eliminating 
septic complications, in extending the field 

July 22. 1893. 



of operative surgery and, above all, in 
impressively teaching the truth of its 
fundamental principle,asepsis,has achieved 
a notable triumph over all older methods. 

It is perhaps remarkable that in general 
surgery there is no great difference in 
the success of those surgeons who rely 
upon boiling water, baked cotton, soap 
and the scrubbing brush — in a word clean- 
liness, and the success of those who have 
faithfully used bichloride of mercury, 
potassium permanganate, carbolic acid, 
hydronaphthol,or creolin, zinc or iodoform. 
Even the careless ones who occasionally 
let their sutures drag across the table, or 
who adjust eyeglasses without again cleans- 
ing their hands, have obtained results not 
much inferior to those of the most scrupu- 
lous followers of modified Listerism. 
After all, it must be remembered that 
antisepsis, or asepsis, is not a ritual but 
a means to an end, and perhaps the very 
men v/hom to-day we call careless, deserve 
the name no more than do those who have 
taught us that air — even the air of a 
crowded amphitheatre — may be admitted 
about a wound with impunity, and that the 
continuous antiseptic spray is not only 
useless but dangerous. 

One after another have the idols of an- 
tiseptic surgery tottered beneath the blows 
of bacteriology. Bacteria have lived in 
dry iodoform; carbolic acid to be rapidly 
efficient in killing or paralyzing germs 
must be intolerably strong, and, vice versa, 
if tolerable, its solutions are practically 
useless save for extremely slow disinfec- 
tion ; we have seen mould grow on leather 
over which a hydro-naphthol solution had 
been spilled, and even corrosive sublimate 
solutions are now alleged to be resisted by 
bacteria rolled up in silk or catgut 
threads. In fact, boiling water and the 
actual flame are almost the only germi- 
cidal agents in which we may believe. 

Why then has the antiseptic surgery of 
the past few years, based, as we are now 
informed, on exaggerated ideas of the ef- 

ficacy of chemicals, and too often practiced 
inconsistently or negligently, yielded such 
magnificent results? Why is it that 
methods so utterly different in detail that 
the uninitiated would not dream of trac- 
ing them back to a common belief in the 
malevolent action of vegetable germs, 
have been in accord in leading to the 
prompt healing of wounds without sup- 
puration? We can scarcely hold that sin- 
cerity of purpose would bring the same 
result from such varied modes of practice 
and must look for a common-place expla- 
nation. It would seem that the tests ap- 
plied to antiseptic reagents by bacteriolo- 
gists have been too rigorous. The 
bacteria experimented with have, for the 
most part, been taken from pure cultures, 
and have been abnormally abundant and 
virulent. The conservative element of 
phagocytosis has been lacking, and in 
many instances spore-bearing bacilli of 
exceptional resisting powers, and, fortu- 
nately, of considerable rarity, have been 
selected. It must be born in mind that 
bacteria are but peculiar kinds of weeds, a 
few hundred or thousand of which may 
do little harm and may even be choked 
out of existence by the phagocytes. 
Moreover, the ordinary septic germs are 
not very hardy plants and they are quite 
easily killed or at least reduced to insigni- 
ficance by the chemicals which fail in the 
case of such vigorous exotics as the 
anthrax bacillus. 

In general surgery the issue between 
asepsis and antisepsis is mostly a question 
of the surgeon and his surroundings. 
The man who has the habit of cleanliness 
— who keeps clean his own person, his in- 
struments, his assistants, his nurses as 
well as his patients and surroundings — 
who has the time and patience to acquire 
cleanliness and who can control surround- 
ings to an extent sufficient to maintain it, 
(nothing is more difficult than to be clean 
surgically speaking), such a one may well 
advocate the practice of asepsis to the ex- 



Vol. Ixix 

elusion of chemical substitutes. But the 
every day practitioner who cannot control 
his surroundings, who is unable to avoid 
contact with contamination^ who may be 
frequently and unexpectedly exposed to 
contagion and to the ordinary saprogenic 
and hypogenic germs, who must accept 
required assistance of the most unsatisfac- 
tory character, who has to combat dirt and 

ignorant relatives even more than disease, 
whose facilities and equipments are meagre 
and imperfect and who cannot maintain 
even if he can acquire cleanliness — it is well 
for such a one to reinforce his imperfect 
efforts at asepsis by any or all chemical 
agents he can bring to his aid. Asepsis is 
the ideal condition, antisepsis a means for 
attaining it. 



Ninay {Le. Bull Med, June 7, 1893) 
remarks that inflammation of the ureter 
and renal pelvis in the course of gestation 
has but slightly attracted the attention 
of physicians and obstetricians, either 
because it is an affection very rarely 
observed or rather because the signs 
and symptoms which accompany it 
have been unrecognized and reported as 
cystitis. The onset of the complication 
is variable. At times it produces much 
disturbance in the form of grave general 
symptoms with chills, vomiting, acute 
pains ; again the progress is most insidious 
and tedious, the phenomena less accentu- 
ated, the pyelitis is added to an already 
existing nephritis and manifests ibself 
under the title of this simple complica- 
tion. Two patients are reported, as fol- 
lows : the first a young woman of twenty- 
six, primipara "at the eighth month of 
pregnancy. She was exposed to a cold 
spell of weather and at the same time 
became much fatigued by walking a long 
distance. In the evening she experienced 
a violent chill, followed by three others 
during the night. Her temperature rose 
to 40° C. ; there was no vomiting, 
diarrhoea, nor cephalalgia, urine was scanty, 
there was but slight painful micturition, 
and the urine contained an abundance of 
pus, was acid, but there were no casts or 
blood corpuscles. At the same time there 
appeared an acute pain in the right flank 
and corresponding renal region. Pressure 
increased this pain, which prevented the 

f Translated for The Medical and Surgical Repor- 
ter, by W. A. N. Borland, M.D. 

patient from moving, so that she could 
scarcely turn herself in bed. Three days 
later after an instrumental labor she was 
delivered of a living child. Fever a!nd 
pain persisted for several days, the urine 
remained purulent for a still longer period 
and convalescence was prolonged. The 
second patient presented a history and 
clinical course almost identical with this. 
The principal symptoms of this con- 
dition of acute inflammation of the pelvis 
of the kidney are lateral abdominal pain 
over the renal region, radiating down the 
ureter and extending to the bladder, but 
slight trouble with micturition, indiffer- 
ence to pressure over the bladder, the 
capacity of which always remains con- 
siderable, the fever and general symptoms 
in proportion to the infection, and finally 
the presence in the urine of innumerable 
pus corpuscles. The predisposing causes 
are the congestive state, traumatism, and 
retention; the determining cause is 
microbic infection. The congestive state 
is not an additional circumstance; it is 
common to pregnancy and the J)uerperium. 
Eetention is especially frequent during 
pregnancy, whilst contusions of the ureter 
are the exclusive consequences of the oper- 
ations and traumatisms that accompany 
parturition. From the point of view of 
the predisposing causes there is a certain 
difference between the pyelitis that pre- 
cedes delivery and that which follows. 
During pregnancy we observe to intervene 
the retention and urinary stasis that are 
determined by compression of the ureter 
in its pelvic course. This compression 

July 82, 1893. 



only exists on the right side. It is the 
rule in this form of pyelitis, and if 
purulent pyelitis of the left side exists it 
is extremely rare and always consecutive 
to parturition. Its origin, moreover, is 
distinct; it is an extension from an 
already infected bladder. The infection 
which propagates itself by rising from 
the bladder affects indifferently either of 
the ureters. 

Compression of the ureter was noticed in 
1870, by Halbersma who regarded it as a 
favorable condition for the development 
puerperal eclampsia. But, long before 
him, Cruveilhier had drawn attention to the 
fact that increase of the lower uterine seg- 
ment produced a compression of this canal, 
as observed upon the cadavers of pregnant 
vfomen dead before delivery. The ana- 
tomical reason of this peculiarity is with- 
out doubt the usual inclination of the 
uterus to the right side, and as the iliac 
artery juts out more markedly on this 
side it becomes easy for the ureter to be 
compressed between this vessel and the 
presenting fetal part. The existence of 
general symptoms more or less grave, the 
presence of pus in the urine, show that 
there is present an infectious disease, be- 
cause we may legitimately apply to pyeli- 
tis the precept that Guyon has indicat- 
ed for cystitis; there is no pyelitis without 

The renal retention that results from 
the compression of the ureter is incapable 
of itself of provoking a persistant inflam- 
mation. The intervention of an infectious 
agent is necessary. The interesting re- 
searches of Eeblaub have furnished us 
with some ideas as to the nature of this 
agent. He has observed constantly in the 
urine of patients with pyelitis, the lacter- 
ium colli. This habitual inhabitant of 
the intestine is not pathogenic under ordin- 
ary circumstances, but it may acquire vir- 
ulent properties under the influence of 
course poorly defined, among which may 
be mentioned chilling, fatigue, errors of 
diet. If the colli bacillus become viru- 
lent, fixes itself upon the mucosa of the 
renal pelvis, it is because this place is 
modified and its soil has become favora- 
ble to the localization. 

The progress of pyelitis occurring in the 
course of pregnancy varies ; at times the 
effection is simple — rest will cure it; at 
other times the gravity of the general 
symptoms interrupts the pregnancy, and 

parturition puts an end to the symptoms. 
The diagnosis is, Vinay believes, nearly 
always easy. The progress is generally 
not very grave. Miscarriage may result 
in some cases, and after the emptying of 
the uterus the symptoms pass away. As 
regards treatment, in the benign forms, 
horizontal repose, baths, regimen, and 
proper hygiene will suffice to cause an 
amelioration if not a disappearance of th e 
symptons. Emollient drinks in large 
quantities, and the use of milk in the form 
of a mixed diet to the amount of 1^ to 
2 liters daily may be added. Absolute milk 
diet will be necessary if a nephritis com- 
plicates the pyelitis. The employment of 
mineral waters is often of value ; the best 
are the feebly alkaline waters, as the wa- 
ters of Ponguer, Alet, and Vittel. Local 
vessicants, sinapsiams and subcutaneous 
injections of morphine are serviceable. 
If there should be sufficient gravity of the 
symtoms, menacing the life of the patient, 
labor may be induced. 

Abnormal Development of the Teeth, 
Forming Tumors of the Jaw.* 

Dr. 0. Hildebrand, of Gottingen, 
makes a further statement upon the case 
which he reported in 1889, in which the 
child of 12 years, who had been submitted 
to various operations, had been relieved of 
between 150 and 200 teeth of various sizes. 

In July, 1891, patient had again pre- 
sented itself at the Gottingen Surgical 
Clinic; both lower jaws were much thick- 
ened, as also the right upper jaw. On the 
whole there were found 17 teeth, part of 
them normally developed, others in an un- 
developed condition; their position was 
deviated and irregular. 

From ,the upper and lower jaw there 
were again some masses of teeth removed, 
which had the same confirmation as those 
formerly described, and presented about 
150 teeth; aside from this, there were 
found two round glassy bodies about the 
size of two peas, which upon microscopi- 
cal investigations showed themselves to 
consist of tooth structure. The con- 
struction of teeth in this patient will 
continue, in all probability, until the soft 
tissues have all reached their final develop- 
ment, which will include the epithelial 
structure of the teeth. — Deutsch Ztschr. f. 
Ohir., 35-5-6—93. 

^Translated for The Medical and Surgical Repor- 
ter by Marie B. Werner, M. D. 



Vol. Ixix 



The author's (Helferich) metliod con- 
sists, in the above named classes, in 

1-Laparotomy at the typical place of 
the left Iliac Fossa, the incision being 
made large enough to find the Aponeurosis 
of the oblique abdominal externis muscle. 
This is sufficiently divided to make it 
possible to form an artificial sphincter. 

2-The Flexura Sigmoidea is drawn for-^ 
ward with the finger or with a hem astatic 

3- In order to prevent the hernia of the 
intestines, the upper portion of the Flex- 
ura must be stretched slightly in its attach- 
ments, with a rubber drain previously 
surrounded by an iodoform gauze. 

4-Consists of a secondary opening of 
the intestinal loop, three to six days after 
the first operation, no narcosis ; a spindle 
form piece is cut out of the loop. 

The results obtained by the author 

have been on the whole very good, there 
having been a general increase of the 
patients' health after the operation. 

In gastrotomy Helferich makes use of the 
rectus abdominis, which he splits parallel 
to the mucle fibre, in order to form the 
sphincter. The opening through per- 
inaeum muscles and skin is when united 
to the walls of the stomach which has 
been drawn forward ; it is united by cat- 
gut, and apex is fixed with silk sutures. 
The stomach is then opened, a relatively 
thick walled rubber drain is inserted and 
fixed into the wound of the stomach. 
Drains are tied with silk transversely over 
the abdominal wound. 

The three cases operated upon were 
conspicuous by the prompt success of the 
operation, and above all, since then alimen- 
tation is continued without any difficul- 
ties. — Deutsche Med. Wochen 1893. 



In an admirable lecture upon this sub- 
ject, Herman {Provincial MedicalJournal^ 
vol. xii.. No. 138) states that about one- 
half the patients who consult a specialist 
for diseases of women complain of pain 
in passing water; but it is only the dis- 
eases which cause severe pain which re- 
quire special treatment, so far as the 
urethra and bladder are concerned. All 
these cases of severe pain depend upon 
local diseases, which can only be dis- 
covered by direct examination. There 
are three places in which disease may 
exist occasioning this suffering, — namely, 
the meatus urinarius, the urethra, and 
the bladder. Pain in the meatus uri- 
narius may be caused by urethral car- 
uncle, by chronic congestion or suppura- 
ting cyst of the urethra, by abscess of the 
urethro- vaginal septum, or by a tender, 
congested candition of the urethral 
mucous membrane. Chronic congestion 
of the urethra is chiefly seen in pregnant 

women; the urethra is swollen and tender 
and feels like a thick cord. Not only the 
act of micturition, but sexual intercourse 
may occasion almost unbearable suffering. 

The treatment for this condition is 
complete rest, cold sponging on the part, 
cold hip-baths, the use of vaginal astrin- 
gent injections, one or two leeches ap- 
plied by a glass leech-tube to the swollen 
and tender urethra, and gentle laxatives. 

Chronic abscess of the urethra- vaginal 
septum is rare, and is characterized by a 
tense, hard, convex, bullous, very tender 
swelling between the urethra and vagina. 

The treatment is evacuation. If there 
is a spot on the vaginal aspect of the 
swelling which is thin, and fluctuation is 
felt, the proper course would be to cut 
into this thin part. If there is no such 
spot the urethra should be dilated under 
an anaesthetic until the canal will admit 
the finger, and the purulent collection can 
be evacuated through the urethra. 

July 22, 1893. 



Suppurating cysts of the urethra form 
a pouch communicating with this mucous 
canal by a narrow, somewhat valvular, 
opening; urine gets into the pouch, de- 
composes, and inflames the sac. On 
examination, a round, tender swelling is 
found in the urethro- vaginal septum, 
varying in size from that of a pea to that 
of a hen's egg. By pressure there will be 
voided either urine or urine and pus, 
sebacious matter, or a calcareous deposit, 
depending upon the nature of the cyst. 
These cysts do not run the course of an 
abscess, which gradually close up once an 
opening has been made for the escape of 
pus, but they continue indefinitely in the 
same state, alternately filling with pus and 
urine, and being partially emptied by 

The treatment is excision of the whole 
or greater part of the cyst-wall. This is 
best accomplished by first laying open the 
cyst freely from the vagina. What is 
next to be done depends upon the skill of 
the operator. The cyst- wall should be 
dissected out and the raw surfaces brought 
in contact by means of either cat-gut or 
shotted sutures. If a portion of the cyst 
near the opening is left and the rest is 
closed, the object of the operation will 
nevertheless probably be obtained, for if 
the pouch is obliterated there will be no 
place in which the urine can be retained 
and decomposed, and therefore no in- 
flammation. If the operator mistrusts 
his manipulative skill, it may be enough 
simply to open the cyst freely from the 
vagina, and then, by keeping the vaginal 
opening from closing by packing with lint 
or gauze, retention of fluid in the cyst 
will be prevented, the urethral opening 
may close, and then the cyst will be left 
with an opening only into the vagina. If 
no more urine gets into the cyst-cavity, 
inflammation will subside and no further 
symptoms will be exhibited. 

If there be much inflammation of the 
cyst, of the urethra, or of the bladder, it 
may be well to make no attempt at closing 
the opening until such inflammation has 
been subdued by appropriate treatment. 
If the cyst is suppurative, or not open, or 
the urethral opening of an inflamed diver- 
ticulum has become closed, the condition 
cannot be distinguished from an abscess. 
When the pus-cavity has been opened, its 
cystic character will be inferred from 
its definite smooth fibrous wall. An 

abscess has not a thick fibrous wall. 
The inside of a diverticulum may 
be trabeculated, so that the origin 
of the pus-cavity cannot always be 
surely made out from the feel of the 
interior. If the cavity be an abscess, it 
will quickly fill up ; if it does not quickly 
become obliterated, it should be treated as 
a cyst. In some cases the patient will 
complain of severe burning, cutting pain 
at each act of micturition, but the meatus 
will be found to be healthy, nor on pal- 
pation through the vagina can any area of 
inflammation be felt. On urethroscopic 
examination of the mucous membrane it 
will be found a vivid red or deep purple, 
appearing in patches or involving the 
whole mucous surface. Passage of the 
catheter is extremely painful. 

The treatment is to apply some altera- 
tive to the diseased mucous membrane; 
the best, in the author's opinion, is iodo- 
form. The application is most conveni- 
ently made by putting into the urethra a 
bougie made of iodoform and cacao butter. 
A little wool put between the labia will 
prevent the bougie from slipping out. In 
recent cases the use of three or four 
bougies will cure the patient. In cases of 
very long standing more prolonged treat- 
ment will be required. Nitrate of silver 
is also serviceable in this condition. In 
some cases application of nitric acid to the 
tender part is followed by relief. Dilata- 
tion of the urethra is also to be recom- 
mended. In some cases both the meatus 
and urethra are healthy, but on passing a 
bougie great pain is experienced as it 
enters the bladder. In these cases a 
urethroscopic examination will show either 
hypersemia or fissure of the vesical neck, 
the symptoms of extreme pain on mictu- 
rition persisting afterwards; also great 
frequency, and difficulty in emptying the 
bladder. Sometimes a little blood escapes 
with the urine. The urine is clear, and 
there is tenderness about the vesical neck. 
Direct examination shows the fissure as a 
small grayish ulceration, with red, inflam- 
ed edges at the vesical neck. 

The treatment consist in dilatation of 
the uretha under anaesthesia ; this is best 
accomplished by meana of Hegar's dila- 
tators until the urethra admits the finger. 
Temporary benefit always follows this 
procedure, and sometimes permanent 
cure. The objects to this treatment are 
that there is danger of septic infection of 



Vol. Ixix 

the bladder and of permanent loss of con- 
trol over the sphincter. Inconvenience 
rarely results unless dilatation is carried 
beyond the point necessary to admit the 
finger. In case dilatation is unsuccessful 
in relieving symptoms, vaginal cystotomy 
is indicated. To preform this operation 
a director should be introduced into the 
uretha and held exactly in the middle 
line. Open the bladder from the vagina 
by catting upon the director. If the in- 
cision is exactly median, no important 
part can be wounded. To prevent this 
opening from closing, Greenhalgh's India- 
rubber stem may be employed, or the 
vesical mucous membrane may be sewed 
to the vagina on each side by a catgut 
stitch. All pain ceases at once, and if 
the artificial fistula is kept open long 
enough, the ulcer heals, and then the 
fistula can be closed and the patient re- 
mains well. 

To minimize the discomfort of the arti- 
ficial incontinence resulting from this 

operation, the patient should be kept upon 
a fracture-bed. The rest in bed is of 
itself beneficial. If nothing is done to 
prevent the healing of such an incision 
of the bladder, it soon either heals or con- 
tracts to a canal only large enough to 
admit a probe. As to how long this fistula 
should be kept open no rule can be given. 
If as the fistula heals symptoms return, 
the artificial opening should be again en- 

Baker^s method of treating these cases is 
to keep the patients in bed for only a few 
days, then to fit them with a urinal, and 
allow them to get up and enjoy fresh air 
and exercise. The fistula is kept open 
for months, and is not closed until the 
interior of the bladder has ceased to be 
tender and, in case of cystitis, until all 
trace of pus or blood has disappeared from 
the urine. This, however, sacrifices the 
advantages of rest, and it has the discom- 
fort of constant soiling of the clothing. — 
Therapeutic Gaz. 


In speaking on this subject before the 
Capital District Medical Society, the 
author states that he approaches it with 
an unaffected timidity and difference to 
open it for discussion. 

I am thoroughly aware of the difficulties 
surrounding the matter, and more especi- 
ally since all that may be, or can be, said 
will be largely of a speculative character. 

There is one curious feature connected 
with the subject: it is also an incontro- 
vertible fact, which has its weight in the 
consideration of this subject. I refer to 
the fact that — no matter what the cause, 
whether from battle or otherwise — when- 
ever there is a large depletion of the male 
population, nature brings about an equi- 
librium by bringing a majority of males 
into the world. It matters not by what 
name you denominate the causes tending 
to this fact, one will necessarily conclude 
that it is divine, — a reason being, that a 
great preponderance of females and a 
scarcity of males would lead to social dis- 
aster and ruin. This is not exactly pre- 
destination, but a physiological process 
left partly. to ''' chance; " but now, I hope, 
under the control of man. 

The best state of society is found where 
the sexes assume about equal numbers. 
The apparently most natural and at the 
same time easy deduction is, that the sex 
is regulated by direct divine intervention. 
Granting this, the subject would be at 
rest : there remains nothing more to be said. 

I have given the subject close attention, 
careful consideration, and diligent study; 
and, without arrogance, I think I have 
discovered the true theory. 

That a great boon would result to 
humanity were this the case, there can be 
no doubt. Hereditary habits could be 
corrected, etc. ; for the reason that female 
children are less likely to become victims 
of the various hereditary habits than male 
children. Along with this, however, 
would come the danger of an unequal pro- 
portion of the sexes. 

There are, as far as I know, four theo- 
ries^ exclusive of divine interference, that 
have been advanced, none of which seem 
to be satisfactory. 

1. — If conception takes place in the 
dark of the moon, the child will be a boy; 
if in the light of the moon, it will be a girl. 
This is too absurd for consideration. 

July 22, 1893. 



2. All the eggs in one ovary are male 
eggs, and all in the other are female eggs. 
This cannot be accepted, as women have 
frequently given birth to both male and 
female children after one ovary had been 

3. If conception takes place before 
menstruation, the child will be a male, if 
after menstruation, a female. This is con- 
tradicted by the fact that male as well as 
female children have been born to women 
who were separated from their husbands 
either before or after menstruation. 

4. If at the time of conception the 
sexual desire and passion is greater in the 
father, the child will be a female ; and vice 
versa. This will not hold good, as many 
women who have never felt any satisfaction 
in sexual congress have given birth to both 
male and female children. 

Let us now direct our attention to what 
I consider the true theory. In the stroma, 
or body of ovaries, are found 7,000 to 
30,000 ovules or eggs, which ripen and 
mature, from one to six at a time, about 
once a month : one-half of these are male 
eggs, and will develop into male children; 
one-half female eggs, which will develop 
into female children. Ripening takes place 
alternately ; first a male egg, next a female 
egg, etc. 

That sounds very well, but the critic 
asks: Can you prove it? I think the fol- 
lowing authentic and carefully-selected 
statistics, collected during the last three 
years, will establish the fact almost beyond 
controversy. I find one case where a 
young girl became pregnant at the first 
menstruation ; the child was a male ; two 
that became pregnant at the fourth men- 
struation, each bearing a female child ; 
one that became pregnant at the 5th men- 
struation, the result a male child; 7 that 
became pregnant at the 10th menstru- 
ation, all bearing female children; 12 
becoming pregnant at the 25th menstru- 
ation, all the children being males ; one 
becoming pregnant at the 54th menstru- 
ation, a girl being the result. In case of 
twins, two eggs have ripened at a time if 
the children are of different sexes ; if of 
the same sex, three eggs have ripened, — 
one failing to become impregnated. I 
have found three corpora lutea in a patient 
who had died of puerperal eclampsia after 
giving birth to two male children. 

If a woman becomes pregnant at the 
next menstruation after giving birth to a 
niale child, the offspring will be a female, 
and vice versa. I found six women who 
became pregnant at next menstruation 
after giving birth to a male child, and the 
result was a female offspring; one case 
where a woman became pregnant at 2d 
menstruation after, and the child was a 
male, 10 cases at 5th, and 8 cases at 6th, 
with the expected result. (*) 

But what about a hermaphrodite f In 
my opinion, there is no such condition ; it 
must be either one sex or the other. The 
supposed penis is either an enlarged 
clitoris or a malformation. 

— Amer. Med.- Surg. Bulletin. 

The Use of Thiol in the Treatment of Burns. 

Bidder {Archiv fur Minishe CMrurgie,'Bsind 
xliii., 1892) says that in treating burns a dress- 
ing should be selected that does not require 
frequent changing. 

Thiol may be used in two forms, the fluid 
and the powder. Its action on the burnt sur- 
face is : 

(i) As a drying substance. 

(2) Relieves the pain. 

(3) Hardens the new skin. 

(4) Hinders the growth of all micro-organisms that 
may have gained entrance to the wounded parts. 

Treatment of Comedones. 

Dr. H. Von Hebra {Hospitals- Tidende, No. 
11, 1893) prescibes the two following solutions 
in the treatment of blackheads : 

1. T> Rosewater, ) 

XJkJ Alcohol, y aa gms. io(5ijss) 

Glycerine, j 

Borax gms. 5 (5j%) 

Shaking before using, 

2. T>, Green soap gms. 4o(gj%) 

±)o Spir. lavender gms. 10 (Bijss) 

Alcohol gms. 80 (Bijss) 

Every morning wash the skin with No. x, and then rub 
in No. 2 . Then wash off with warm water. 

Naso=Pharnygeal Catarrh of Nurslings. 

Dr. Neumann {La Semaine Medicate, No. 
33, 1892) has obtained excellent results in the 
treatment of naso-pharnygeal catarrh, so 
severe even as to interfere with nursing, by 
employment of the following solution: 

T>, Sulphate of zinc gms. jss) 

J^ Water gms. 15 (5iv) 

Instill a few drops of this solution into each nostril 
several times a day. 

* The author's theory fails, however, to explain the 
fact — quoted by himself — of the preponderance of male 
births in a region largely depopulated of males, and 
vice versa; unless he brings the 4th of the current 
theories, alDOve cited, to his aid: to the effect that 
fecundation, under a scarcity of males, will more 
readily occur on the male ova, on account of the more 
intensive orgasm on the woman's part. — [Ed.] 


Selected Formulce. 

Vol. Ixix 

Treatment of Hyperidrosis. 

Several new lormulse for the treatment of 
sweating hands and feet have been recently 
introduced. The following are among the 
best of them: 

The Monatshefle fur Prak. Dermal, re- 
commends an alcoholic solution of borac acid, 
borax, and salicylic acid, as follows: 

T3 Boric acid Sj 

-P& Borax 

Salicylic acid aa gij 

Alcohol Svj 

Mix and make a solution, with which rub the palms of 

the hands or soles of the feet thrice daily. 

The Centralblatt fur die Oesammate The- 
rapie recommends the following mixed treat- 

T> Betanapthol 5ij 

X>y Glycerin Sss 

Alcohol S V 

Mix and dissolve. Use as a wash to the parts afifected 
twice daily; dry, and apply the following powder: 

T> Beta naphthol gr. xxiv 

-TV Starch 3v 

M. Pulverize and mix. 


Bromidism may be prevented by combin- 
ing an intestinal antiseptic with each dose of 
the bromide salt as follows: 

TX Potassii bromidi gr. xxx 

-M^ Beta naphthol gr. xx 

Sodii salicylat gr. x 


Eczema of the Vulva. 

Lusch employs the following : 

"P, Tincturse opii I ^3 o 

-t)k? Sodii bicarbonatis f ^^ ^^^- ^ 

Potassi bicarbonatis gms. 4 

Glycerini gms. 6 

Aquae destil gms. 206 

Prof. Graham is of the opinion that the 
prognosis of hereditary syphilis in children 
will depend to a great extent on the length 
of time that elapses between the birth and the 
appearance of the eruption. The sooner the 
eruption appears after birth, the better will 
the prognosis be. 


T> Pelleturin sulph gr. vi-viiss. 

X^ Pulv. acid tannic gr. viiss. 

Syr. simpl 5ij 

M. Sig.— Take the above the following morning before 
breakfast. Fifteen minutes after take two tablespoon- 
fuls of castor oil. 

— Lahbe, Ex.. 


Dr. G. T. Elliot prescribes : 

^ ?SLf/uWet.} aag— 

Aquse rosae Sj 

Sulphuris praecip grs. xx-xl 

M. Sig.— Apply to face three times a day. 

Embalming is accomplished by a new 
process attributed to Dubois, a Frenchman, 
in which the body is dehydrated by means of 
amylic alcohol or nitric ether, or a mixture of 
both injected in the usual way. It is placed 
in an air-tight chamber and surrounded with 
calcium chloride and its entire surface is 
eventually coated with a solution composed 
of balsam tolu and benzoin in equal parts in 
ten times their weight of either. According 
to the Br. and Col. Dr., the body is said to re- 
tain its natural appearance. 


Brown Leather Polish. 

Annatto 5^ ounce 

Catechu i ounce 

Gamboge ^ ounce 

Gum acacia J4 ounce 

Hydrochloric acid i fluidounce 

Water. , 2 pints 

— Bulletin of Pharmacy. 

Prof. Hare gives the following prescrip- 
tion as useful in the sub-acute stages of bron- 
chitis : 

T>, Vini ipecac f5j 

JP^ Tinct scillae f 5ij 

Syrup tolutan f3v 

Aquse destillat fSj 

M. Sig.— Teaspoonful every three hours. 

Prof. Keen gives the following formula for 
Morton's fluid ; useful where absorption is re- 
quired : 

T> lodinii gr. x 

1^ Potassi iodidi gr. xxx 

Glycerini fSj 

M. Sig.— Use locally. 

Liquid Spice Plaster. 

Med. Bulletin. 




Ginger, of each, 4 drs 
Exhaust with stronger alcohol, evaporate to 4 ozs. and 
add to a solution of 

Rosin , 9 ozs to 2 lbs. 

Venice turpentine 7 ozs. 

Alcohol (95 per cent.) 12 ozs. 

Spread with a camel's hair brush on paper covered with 
muslin, and apply in lunabago, muscular rheumatism 
pain in chest, etc., over place of pain. 

A Deodorizer for Iodoform. 

The following {Norsk Magazinfur Loegevi- 
denskaben, No. 3, 1893) is recommended : 


Iodoform gms. 187 (Svj) 

Carbolic acid gms. i (gtts. xv) 

Oil of peppermint gms. 2 ( 

July 22, 1893. Current Literature. 




for July. Dr. J. Whitridge Williams con- 
tributes an article on 

Calcified Tumors of the Ovary. 

He reports two cases of the disease and one 
case of calcified corpus luteum. He also says 
that, in several instances, the tumors sent 
him for examination as osteoma of the ovary 
proved to be simply calcified fibromata and 
in one instance, what was supposed to be a 
nodule of true bone was found to be a calci- 
fied corpus luteum. He further says that 
while true osseous tumors also occur in the 
ovary they are even more rare than calcified 
tumors. Of course, in speaking of calcified 
tumors of the ovary, all growths which are 
connected with dermoid tumors are ex- 
cluded. The process of calcification is always 
preceded by more or less necrosis of the af- 
fected part. All forms of necrosis do not 
lead to calcification but particularly coagula- 
tion necrosis and then only under certain 
conditions. The general law in regard to the 
production of calcareous deposits seems to be 
coagulation necrosis to which some supply of 
blood or lymph is admitted. The clinical 
history of calcified tumors of the ovary does 
not oifer any distinguishing features from 
other solid tumors of the ovary. They rarely 
attain great size; in one or two cases there 
was marked dysmenorrhoea; in several cases 
there was marked uterine hemorrhage, 
which ceased after the removal of the 
growths. It is impossible to distinguish the 
condition under consideration from other 
hard tumors of the ovary; when n the diagno- 
sis has by any possibility been made, the re- 
moval of the tumor is indicated. 

Dr. Charles M. Green contributes a paper 

Puerperal Eclampsia, 

giving the results in the Boston Lying-in- 
Hospital during the last eight years. As to 
the treatment of ante-partum eclampsia: 
Ether was used to control the convulsion and 
he believes that it is as safe as chloroform for 
that purpose. Chloral hydrate by the rec- 
tum was used as a sedative between the at- 
tacks. Morphia is not approved of, as in 
some cases it seemed to cause restlessness. 
The action of the skin is excited by means of 
the hot bath, hot air bath, etc., and for 
drugs, pilocarpin in gr. I doses, guarded by 
stimulants. If the skin does not act readily, 
the bowels are moved by croton oil or elater- 
ium. Cream of tartar water and digitalis are 
used as diuretics. Venesection has not been 
resorted to. When it becomes necessary to 
deliver the patient rapidly, manual dilatation 
of the cervix is preferred to dilators or hydro- 
stasic bags. Podalic version and manual 
extraction are preferred to forceps, unless the 
head is engaged. When the attack occurs 
during labor, it is the practice to deliver as 
speedily as possible. After delivery, chief 
reliance is placed on chloral, pilocarpin, hot 

bathing or the hot air bath, mild diuretics, 
and necessary stimulation. Post-partum 
eclampsia is treated, in general, in the same 
manner as in inter-partum cases after the 
labor has been completed. If symptoms of 
threatening convulsions appear during 
delivery, the labor is not hastened, if pro- 
gressing normally, and treatment is directed 
toward allaying nervous symptoms and 
mildly stimulating the function of the kid- 
ney. The paper includes tables showing the 
number of cases treated and the results. 

Dr. Reuben Peterson discusses the subject 

Tubal and Peritoneal Tuberculosis, 

reporting four cases. He comes to the follow- 
ing conculsions : 

1. Tubal tuberculosis, either alone or with 
coexisting involvement of the peritoneum, is 
far more frequent in occurrence than is 
commonly supposed. 

2. Early operative interference is indicated 
in the presence of either tubal or peritoneal 
tuberculosis, as a safeguard against the further 
extension of the disease. 

3. All cases of tubal or peritoneal tuber- 
culosis subjected to a laparotomy should be 
drained, and whenever practicable, the iodo- 
form gauze drain should be employed. 

Dr. George M. Edebohls contributes a 
paper on 

The Operative Treatment of Complete Pro= 
lapsus Uteri et Vaginae. 

The author states that, until such time as 
it can be shown that the results acheived by 
total extirpation of the uterus for prolapsus 
are better and more lasting, as well as that 
the operation is no more dangerous than the 
rival procedure, he will adhere to ventrofixa- 
tion of the uterus combined with the necessary 
plastic operations as the' rule, practicing total 
extirpation only on exceptional j^indications, 
as : 

1. A uterus so large and heavy as that it 
cannot be reduced to an approximately 
normal size and weight by amputation of 
the cervix. 

2. A uterus presenting either positive evi- 
dence or strong suspicion of malignant disease. 

3. A uterus with appendages so diseased that 
the condition of ovaries and tubes calls for 
their removal, apart from other considera- 

The author would also lay it down as an 
axiom that whenever the uterus is preserved 
in prolapsus operations it should be securely 
ventrofixated. The paper also includes a 
table of the twelve cases operated on by the 

Dr. A. F. A. King reports a case of 

Labor Obstructed by Ovarian Tumor. 

In regard to treatment in these cases : The 
author is of the opinion that when the tumor 
is large and below the pelvic brim, and can- 
not be pushed back to make room for the 
child, the only modes of proceeding available 


Current Literature. 

Vol. Ixix 

would seem to be : [1] abdominal section of 
the mother, [2] mutilation of the child, or 
[3] puncture of the tumor. Playfair's tables 
give the best results from puncture of the 
cyst. In cases where the tumor is smaller and 
capable of being pushed up out of the way 
of the child, it becomes an finteresting ques- 
tion whether such a method of treatment, 
with its well known risks, would be better 
than emptying the tumor by puncture. 
Dr. S. C. Gordon discusses the 

Dangers and Complications of Uterine Fbroids. 

The conclusions arrived at are: 

1. Uterine fibroids are always more or less 
troublesome, and in a majority of cases pro- 
duce a state of chronic invalidism. 

2. In a large percentage of cases they are 
complicated with excessive hemorrhages, 
peritonitis, salpingitis, and ovaritis, with 
purulent collections and adhesions, producing 
continual suffering. 

3. Many of them do not cease growing at 
the menopause, but increase. 

4. Many undergo degeneration, either cal- 
careous, cystic, or malignant. 

5. Hysterectomy is not a very dangerous 
operation if made in the early history of the 
case — no more so than ovariotomy. 

6. In addition to the saving of life, it re- 
lieves (in nearly all the cases) the woman 
from the life of invalidism. 

Dr. Charles P. Noble contributes a paper 
on "The Question of Operation in Cases of 
Chronic Ovaritis." The conclusion arrived 
at is that operation should be performed if 
continued well-directed treatment does not 
benefit the patient. Particularly is this the 
case with those women who are dependent 
on their own labor for support. The author 
also urges that all ovaries removed because 
of chronic ovaritis, should be submitted to a 
competent patholgist for careful study, that 
new light many be thrown upon these con- 

Dr. H. Marion Sims contributes a paper 
on " Hystero-epilepsy," reporting seven cases 
cured of the disease by surgical measures. 

Dr. Frank A. Stahl, in a paper on "Digital 
Curetting of the Puerperal Uterus," shows 
very clearly the great advantage of the finger 
over any form of instrument in these con- 

The other papers in the current issue are: 
^' Vaginal Enterocele in Pregnancy and 
Labor," by Dr. Barton C. Hirst; "The 
Abdominal Brain in Gynecology: Its Reflex 
and Rythm," by Dr. F. Byron Robinson, in 
which the author shows the part which the 
sympathetic system plays in abdominal dis- 
eases. The remaining paper is by Dr. Thad. 
A. Reamy on " Membranous Dysmenor- 


for July. 
Dr. J. R. Buist contributes a paper on 

The Management of Retroflexio Uteri, 

in which he has come to the following con- 

1. We believe that in the large majority of 
cases the predominant morbid state allowing 

of retroflexion is to be found in the uterus 
itself; a diseased state of this organ is the 
primum mobile of the trouble. 

2. Next, an extension of the metritic dis- 
ease to the tubes, ovaries, and peritoneum is 
the most usual sequence of changes, and the 
relaxation of ligamentous supports the last. 

3. The skilled gynecologist will treat the 
complications first, resort to pessaries last, 
and when opportunity offers, or the symp- 
toms severe enough, select some one of the 
surgical methods of fixation. 

Dr. E. M. Magruder in a paper on 

Aneurism of the Vertebral Artery— Its Suc= 
cessful Treatment, 

gives the following: 

1. Vertebral aneurism is very rare, and its 
treatment has been exceedingly unsuccessful. 

2. The causes of the lack of success are (1) 
inaccessible situation and (2) errors in diagno- 

3. Of the twenty-eight cases (the author's 
the twenty-eighth) mentioned in the paper, 
three were cured and twenty-five perished. 

4. Of the three cases cured, one was treated 
by cold and direct pressure, one by enlarging 
the original wound and using a styptic and 
bandage, and one (the author's) by a combi- 
nation of incision, evacuation, packing and 

5. Vertebral aneurism can be safely laid 
open and treated, the only danger being im- 
mediate hemorrhage. The requisites for suc- 
cess are quickness and perfect asepsis. 

6 Treatment by incision, evacuation, pack- 
ing, and compression is the safest, easiest 
and surest method yet devised for vertebral 
aneurism, and is bound to succeed. 

Dr. Mathew M. Smith in a paper on 


advises that the use of this agent be limited 
to graduates in medicine. Even then it 
should be confined to its legitimate uses in 
the treatment of disease. As to the con- 
ditions that are cured or benefitted by hypno- 
tism, the author believes that all pains that 
have no automatical lesion, as headaches, 
ovarian, rheumatic and neuralgic pains, 
sleeplessness and hysterical conditions, and 
many disturbances of menstruation, alcohol, 
opium, and tobacco habits may be cured by 
its use. Neurasthenia, stammering, and 
nervous disorders of sight are benefitted by 
it. It may be used in minor surgery and 
labor to diminish pain. In treatment, many 
sittings may be necessary in order to get the 
beneficial results desired. Some physicians 
will have much better success than others 
with its use, just as some surgeons have a 
more skillful use of the knife than others. 

Dr. W. R. Pryor contributes a paper on the 
" Treatment of Sterility." The author believes 
that, in the majority of cases, the endome- 
trium is at fault and advises the dilatation of 
the cervix followed by a through curetting of 
the entire endometrium and packing with 
iodoform gauze. The author reports several 
cases in which the above treatment was 
followed by conception in a short time. 

Dr. John S. Hughson advocates, in a paper 
on "The Treatment of Puerperal Convul- 

July 22, 1893. 



sions," the use of large hypGdermics of mor- 
phia to control the convulsion. 

Dr. B. A. Patterson contributes a paper on 
" The Treatment of Diphtheria." The author 
advocates the use of a mixture of potassium 
chlorate, dilute nauriatic acid, tincture of the 
chloridejof iron andwater, internally, followed 
by the application to the throat of a mixture 
containing one ounce of fluid extract of pinus 
canadensis and ten to fifteen drops of phenic 

Dr. John N. D. Cloud in a paper on " Mal- 
arial Hsematuria," cautions against the use of 
quinine until the hemorrhage has subsided 
and the skin has regained its natural color. 

Under " ClinicalReports," Dr. A. B. Pierce 
reports a case of ovarian tumor which has 
been tapped nineteen times. 

Dr. John Dunn reports a " Case of Complete 
Bony occulsion of One Side of the Nose," 

Other papers in this issue are : " Purulent 
Puerperal Peritonitis," by Dr. Virginius W. 
Harrison ; " Reform Needed as to Medical 
Expert Testimony," by Dr. William B. St. 
John; "A Few Facts in the History of 
Abdominal Surgery" by Dr. Anne Walter ; 
"Organic Syphilis," by Dr. Henry Bobbins ; 
and " What the General Practitioner Should 
Know About Diseases of the Eye " by Dr. 
Frank Trester Smith. 



Terpene Hydrate in Bronchial Catarrh. 

Dr. Wm. Murrell {Med. Age) says: 
I am desirous once more of calling atten- 
tion to the value of terpene hydrate in the 
treatment of affections of the bronchial and 
nasal mucous membranes. Its properties 
have been well known for many years, but 
in this country it has never been a popular 
remedy, and its claims seem to have been 
overlooked in favor of pure terebene and 
other similar compounds. It is a hydrate of 
turpentine, and is made by treating oil of 
turpentine with nitric acid and alcohol. It 
is a solid, and has somewhat the appearance 
of chloral hydrate. Its odor, which is slight, 
resembles that of pure terebene. The great 
difficulty in the way of its administration is 
that it is practically insoluble in water. It 
is usually said to dissolve in alcohol in the 
proportion of 1 in 10, .but many specimens 
are far less soluble. On the Continent, 
where lit enjoys a high reputation in the 
treatment of bronchial affections, it is used 
as a popular remedy in the form of an elixir. 
For some months past I have prescribed it 
in a solution containing five grains to the 
half-ounce, made up with simple elixir and 
flavored either with tincture of Virginia 
prune and syrup of tar or with aqua lauro- 
cerasi. For patients who cannot take sugar 
the elixir may be made with saccharine. 
Terpene not only relieves cough and lessens 
bronchial secretion, but is a diuretic, and has 
been used with advantage in neuralgia. 

Ichthyol in the Treatment of Erysipelas. 

Glinsky states that during the last four 
years he has tried ichthyol with great suc- 
ces in one hundred and twenty-eight cases 
of erysipelas. He concludes that this drug 
is decidedly the best means of all yet pro- 
posed for the treatment of this disease. It 
rapidly arrests the spread of the morbid pro- 
cess and reduces the average duration of the 
disease down to two or three days. The 

method is of the greatest value in all cases 
in which cardiac weakness, due to fatty de- 
generation of the heart, is present in patients 
with nephritis. — Zemsky Wratsch, 1892, Nos. 
39 and 40. 

Chloride of Iron in Diphtheria. 

Drs. Hubner and Rosenthal [Munich Med. 
Woch.) in two separate communications 
speak enthusiastically of the results of treat- 
ing diphtheria by means of the chloride of 
iron. Hubner applied it locally in a 1.1 or 
1.5 solution by means of a swab or brush, 
two or three times a day; Rosenthal, in- 
ternally, in a 20 per cent, solution with 
glycerine as a corrigiens, a teaspoonful to a 
tablespoonful every hour. The results with 
both were astonishingly good. 

The Condition of the Spinal Ganglia in 
Tabes Dorsalis. 

R. Wollenberg states that it is still a mooted 
question whether the seat of the primary 
changes in tabes dorsalis is in the spinal cord 
or outside of it. It is true that changes in the 
peripheral nerves and spinal ganglia have 
been frequently discribed, without its being 
possible, however, to determine their true 
pathogenic importance. In fourteen cases of 
tabes, Wollenberg has made examinations 
with regard to this point, with the following 
results : In the spinal ganglia, in all the 
cases examined, not only the [nerve-fibres and 
the interstitial connective tissue, but also the 
ganglion-cells themselves were found to have 
undergone pathological changes. The excess 
of pigment and the shriveled condition of 
the cells can, of course, not be considered as 
a sure indication of disease ; but this is not 
the case with the opacity of the protoplasm, 
which is always present, and with the 
agglutination of the cells, which may, un- 
doubtedly, be regarded as typical of a path- 
ological process. Although it is thus proven 
that in tabes the spinal ganglia present path- 
ological changes in all their elementary parts, 



Vol. Ixix 

yet these changes of the ganglion-cells may 
be regarded as insignificant in comparison to 
those occuring in the nerve-fibres and in the 
interstitial connective tissue. 

We cannot, therefore, assume that tabes 
originates in the spinal ganglia, nor that the 
latter are the primary seat of the trouble ; 
it is most probable that the changes occur- 
ing in the ganglionic cells of the spinal 
ganglia are only of a secondary nature, and 
are inducedjby a perineuritis developing in the 
region of the spinal-cord process and grad- 
ually involving the nerve-elements (first the 
nerve-fibres, then the ganglionic), cells and 
inducing atrophy. — ArcMv fur Psychiatrie, 
vol. xxiv. 

Arsenical Neuritis. 

Osier {Montreal Med. Jour.) relates a case 
to show that long continuance of full thera- 
peutic doses of arsenic may lead to the 
development of peripheral neuritis. The 
patient was a Pole, suffering from Hodgkiii's 
disease, affecting the cervical, axillary, and 
inguinal glands. During a period of seventy- 
five days he took §iv, sj. mxviii of the liquor 
potassse arsenitis, equivalent to sixteen and 
one-half grains of arsenious acid. The dose, 
for the greater part of the time, with some 
intermissions owing to diarrhoea, was m xv 
three times a day. Increased pigmentation 
of the skin was noticed at an early period of 
the treatment, and, after about seven weeks, 
it was noticed that the muscles of the upper 
and lower limbs were tender to the touch, 
and that he walked stiffly. The knee-jerks 
which were then present had disappeared in 
another fortnight, and he was scarcely able 
to walk at all. The muscular power of the 
arms w^as diminished. The excitability of 
the muscles of the legs to both currents was 
diminished, and A.C.C. was equal to, if not 
greater than, K.C.C. Osier observes that 
idiosyncrasy must play a part in the pro- 
duction of arsenical neuritis, which is very 
rarely produced by therapeutic doses. He 
had only once before met with a case which 
raised the suspicion of neuritis, though he 
has been in the habit of treating pernicious 
anaemia, Hodgkin's disease, and chorea 
minor with arsenic, pushingH:he drug until 
its physiological effects were produced — itch- 
ing of the skin, slight oedema, vomiting, or 


Removal of the Seminal Vesicles. 

Since Ullman removed both seminal vesi- 
cles for tuberculous disease, by Zuckerkandl's 
method — which consists in exposing the 
prostate and base of the bladder, by dividing 
the anterior attachments of the rectum and 
then freeing it from the prostate and lower 
part of the bladder — Roux has reported tw 
cases in which for tuberculous disease he has 
removed one seminal vesicle together with 
the spermatic cord and testicle of the same 
side through a lateral perineal incision. 

reaching the vesicle by a dissection carried 
upward between , the prostate and the rec- 

Dr. George W. Gay, of Boston, in May, 
1891, removed the right seminal vesicle, 
through a lateral perineal incision (similar 
to that practiced by Roux), for cancerous 
disease thought to be primary in the vesicle. 
Six months later the wound, which had 
healed well, reopened; the examination re- 
vealed a hard mass, about the size and shape 
of the forefinger, in the site of the seminal 
vesicle which had been removed. 

Villeneuve reports a case in which he re- 
moved one seminal vesicle by exposing the 
spermatic cord outside the inguinal canal, 
and by freeing and pulling on the cord until 
the seminal vesicle was sufficiently brought 
down to be reached and excised. — Boston 
Med. and Surg. Jour. 


The question of the advisability of this 
operation was lately brought before the pro- 
fession by Mr. Buckstone Brown, who 
recommended the operation when a patient 
had to use a catheter every 2 hours, and 
life was a burden in consequence. He 
quoted the case of a gentleman, set. 72 years, 
on whom he had operated a year ago for a 
small stone and finding the prostrate much 
enlarged he had removed two ounces of the 
gland; the patient can now pass all his water 
without requiring the use of a catheter. The 
general feeling of the society was that the 
supra-pubic method was the best, and that the 
gland should only be removed when obviously 
projecting into the bladder cavity. Bleeding is 
the worst feature of the operation, and can best 
be prevented by using special small toothed 
forceps which crush as well as remove the 
gland. All agreed that there was a con- 
siderable risk in the operation.— Ca^cw^^a 
Med. Bep. 


It was briefly stated in the British Med. 
Journal of February 25, that Dr. Lowson, of 
Hull, had operated on a case of tuberculous 
disease of the lung by removing the right 
apex, to which the disease was limited. We 
are glad to learn that the patient bore the op- 
eration well, and was able to get up for a 
short time in the third week ; she was then 
eating well and had no pain. The operation 
was commenced by the removal of the ante- 
rior third of the second and third ribs ; the 
parietal layer of the pleura was opened and 
the apex of the lung was pulled out after sep- 
arating a- number of extensive adhesions ; the 
diseased apex was then transfixed with a 
needle and strong silk, firmly tied and re- 
moved. The sudden development of pneumo- 
thorax gave very little trouble and oxygen, 
which was at hand, was not needed. The 
respirations were never more than 44, and 
dropped in a day or two to 32, and soon after 
to 24; the pulse showed a similar elevation 
and decline. The highest temperature was 

July 22, 1893. 



101.8°; this occurred in the second week and 
lasted five or six days, with complete morn- 
ing remissions. The wound was quite healed 
by the end of the third week. The after his- 
tory of this patient will be watched with 
much interest. — British Med. Journal. 


Noble (C. T.) on Certain Problems in Ab- 
dominal Surgery; Based on One Hun= 
dred Celiotomies. 

The paper is an elaboration along the lines 
indicated in the following extracts: 

The essentials of success in abdominal sur- 
gery are: 

1. Early operation. 

2. Careful preparation of the patient, with 
especial reference to stimulating the emunc- 
tories and to securing asepsis of the abdom- 
inal wall. 

3. An aseptic operating room. 

4. Aseptic hands and instruments for the 

5. As great rapidity in operating as is com- 
patible with careful, thorough work. 

6. Irrigation and drainage in septic cases. 

7. Careful after-treatment, embracing es- 
pecially the withholding of fluids for about 
forty-eight hours, early purgation and at 
least three weeks' confinement to bed. 

Regarding the question of drainage the 
author says that the better results obtained 
at present without drainage, as compared 
with the results of ten years ago, is explained 
by five facts: 

1. Surgeons do cleaner work; they are more 
aseptic than formerly. 

2. They have better means for securing 

3. They do not use irritating chemical an- 
tiseptic solutions in the peritoneal cavity. 

4. They deprive their patients of water for 
forty-eight hours after operation, thus pro- 
ducing systematic thirst and bringing about 
the absorption of serum from the peritoneal 

5. They purge early and freely on the first 
sign of peritoneal irritation. 

He believes that the use of a drainage tube 
may cause hernia, and that it may prove an 
open door for infection. A carefully com- 
piled table of cases closes this sensible article. 
— Am. Jour. Obstet. 

Vaginitis from Bestiality. 

The patient {Weekly Med. JRev.) was "a 
smart, pretty, well educated " twenty-six- 
year-old country girl, who was found to be 
suffering from a profuse, thick, sticky, green- 
ish yellow vaginal discharge of an extremely 
offensive odor, completely gluing the parts 
together. The discharge had been present 
for about a week, coming on suddenly. 
After washing the external genitals and 
opening the labia three rents were discov- 
ered, one through the fourchette and two 
through the left nymph se. The vagina was 

found to be excessively congested and covered 
with bleeding points on the least irritation. 
Gonorrhoea was the presumptive diagnosis, 
but coitus was denied, albeit menstruation 
was stopped, and the patient was terribly 
perturbed about pregnancy. Under jDres- 
sure, she confessed that one day she was 
playing with the genitals of a large dog. 
She became excited and thought she would 
have slight connection with him, but after 
the dog had made an entrance she was un- 
able to free herself from him, as he clasped 
her so firmly with his fore legs. The penis 
soon became so swollen the dog could not 
free himself, and for more than an hour she 
made the most persistent efforts to do so, 
and finally making the ruptures before 
spoken of, and followed immediately by the 
discharges and inflammation. She was 
given the usual treatment for gonorrhoea, en- 
joining rest and soothing treatment until in- 
flammation had subsided, since which time 
every kind of injection and treatment, ap- 
plied both to the vagina and uterus, has 
failed to cure the discharge, pus cells being 
still abundant in the discharge; menstrua- 
tion is normal. There was reason to suspect 
that the bestiality continued. The case is 
not unique, as Dr. I. C. Rosse ( Va. Med. 
Monthly) reports that a young white single 
woman was surprised copulating with a 
large mastiff", whose endeavors to release 
himself caused fatal vaginal hemorrhage. 
The bony structures of the dog's penis, and 
the reversal attempted after completion of 
the canine sexual act, would be very likely 
to inflict wounds of the kind described in the 
flrst case. — Medical Standard. 

Qonorrhoeal Infection of the Mucous flem- 
brane of the Mouth in New=Borne In= 

From the study of Ave cases of gonorrhoeal 
infection of the mouth in the Konigsberg 
Obsterical Clinic^ Dr. Rosinsky has drawn 
the following picture of the disease : With- 
out preceding inflammatory redness, a white 
discoloration appears upon the anterior two- 
thirds of the tongue, the tongue, the plaques 
of Bednar, the hamulus pterygoideus, and 
along the ligamentum pterygomandibularum 
in the lower jaw, finally upon the front parts 
of the gums. After twenty-four to thirty-six 
hours the color becomes yellow. The patches 
elevate themselves plateau-like over the sur- 
rounding tissues, and their surfaces are raw. 
The superficial epithelium forms with ex- 
travasated pus cells, a thick layer, resembling 
the scrapings from the cut surface of a septic 
spleen. On the third day the regeneration 
of the epithelium begins ; this is marked by 
an inflammatory redness around the edge of 
the patch. Healing follows without treat- 
ment, in an ideal manner, no trace of scar or 
discoloration remaining. From the micro- 
scopical examination of some excised tissue, 
Rosinsky has gleaned the following : The 
gonococci were never found, in stained 
sections, intra-cellular. They were seldom 
found intra-cellular in the superfical flakes. 



Vol. Ixix 

Gonococci cannot penetrate into the body of 
healthy, living cells ; they accomplish this 
only when the single cells are cut off from 
the conditions of life. In the connective 
tissue gonococci invasion was found. Rosin- 
sky believes this to be typical pure gonorrhoea} 
inflammation of the mucous membrane. 
The relatively infrequent gonorrhoeal in- 
flammation of the mucous membrane of the 
mouth in adults, in contradistinction to 
infants, he believes to be due to the tender- 
ness of the epithelium of the mouth in the 
new-born. — Annals of Gynecology. 

this will prove an unecessary precaution, and 
that it will be safe to close the bladder by 
deep sutures."— ianeeiJ. 

A STUDY of the effects of removing the 
ovaries shows that for some time there are 
menstrual molimina and the ordinary signs 
of the climacteric appear. The deposit of fat 
in the abdominal walls, buttocks and other 
parts of the body is attributed not to excess 
of nutrition but to vaso-motor changes. 
When the uterus is removed and the ovaries 
left behind the latter do not atrophy, as has 
been claimed, but subsequent autopsies have 
shown them unchanged in size and contain- 
ing Graafian follicles ripening or breaking. — 
Northwestern Lancet. 

Supra=pubic Lithotomy. 

Lawson tait thus describes the technique of 
this operation : "I make use of no precau- 
tionary measures or preparatory steps. I 
neither pack the rectum nor distend the 
bladder. I stand on the left of my patient 
and^cut upward two inches and a half, start- 
ing immediately over the ridge of the pubic 
arch, exposing the tendon at one sweep. I 
then cut the tendon transversely over about 
one inch close to the bone, and cut it centrally 
for an inch and a half. I thenipass nay left fore- 
finger between the bladder and pubic arch and 
follow it with a pair of forceps . I gently rend 
the tissue till I can feel bladder wall. This 
can easily be detemrined by its peculiar feel- 
ing, and by the fact that once the forceps grip 
it they hold, and they do not hold merely 
cellular tissues. Having fixed one pair, I 
then fix another close to thena. My assistant 
takes them and gently pulls them apart, as 
in abdominal section ; a notch of the knife 
follows, and a rush of water declares the road 
into the bladder for the forefinger to be open. 
The rest is all finger work, and consists as in 
abdominal sections of a gentle, but firm ex- 
tension of the opening into the bladder, till 
the lithotomy forceps can follow it. All my 
cases have recovered without complications, 
and though up to the present I have used a 
glass drainage tube, I am of the opinion that 

Fecal Fistula following Hernia— Closure by 
Resection of Intestine. 

At the London Hospital Mr. Frederick 
Treves recently operated on a boy, set. 16 
years, who, six months ago, had been 
operated on for hernia. Probably the intes- 
tine was gangrenous, as it had been left in 
the wound, and a double fecal fistula re- 
sulted. The double opening in the intestine 
was freely exposed, the gut drawn out, and 
three inches of the ileum were removed. The 
ends were approximated by Lembert's 
suture. — Med. Press and Circular. 


U. S. ARMY FROM JULY 9, 1893, TO JULY 15^ 


The order assigning Captain Freeman V. 
Walker, Assistant Surgeon, to temporary 
duty at Fort Trumbull, Conn., is so amended 
as to relieve him from future duty at Fort D. 
A. Bussell, Wyoming, and to assign hin to 
station at Fort Trumbull, Conn., until 
further orders. 

1st Lieut., Charles F. Mason, Assistant 
Surgeon, July 2, 1893, promoted to be Assis- 
tant Surgeon, with the rank of Captain. 

Major James P. Kimball, Surgeon, is 
relieved from duty at Fort Clark, Texas, to 
take effect at the expiration of his sick leave 
of absence, and ordered to Fort Marcy, New 
Mexico, for duty. 

Major William H. Gardener, Surgeon, on 
being relieved by Major Woodrufl, is ordered 
to duty as Attending Surgeon and examiner 
of Recruits at Steadgrs, Dept. of Dakota, St. 
Paul, Minn., relieving Capt. Walter Reed, 
Assistant Surgeon, U. S. Army. 

Capt. Reed, upon being relieved by Major 
Gardner, is ordered to report to the Surgeon 
General at Washington, D. C, for duty as 
curator of the Army Medical Museum, and 
as I professor of clinical and sanitary micro- 
scopy in the Army Medical School. 

Captain William H. Corbusier, Assistant 
Surgeon is relieved from duty at Fort Wayne, 
Mich., and ordered to Fort Supply, Indian 
Territory, for duty, relieving Major Paul 
R. Brown. Major Brown on being relieved 
by Captain Corbusier is ordered to Port 
Hamilton, N. Y., relieving Major Ezra 
Woodruff, Surgeon Major Woodrufl on being 
relieved by Major Brown is ordered to Fort 
Keogh, Montana, for duty, relieving Major 
William H. Gardner, Surgeon. 

Vol. liXlX, No. 5. 
Whole No. 1900. 

JULY 29, 1893 

$5.00 per Annlini 
10 Cents a Copy 



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RoswELL Park, A. M., M. D., Buffalo, N. Y. 
Pes Planus ; Cyst of Thyroid ; Multiple Uric Acid 
Calculi ; Sarcoma of Jaw with Suspected Syphilis. 163 


Charles Zimmermann, M.D., Milwaukee, Wisconsin. 

The Ej'e-Symptoms of Brain Disease. ... 166 
P. O. Keef, Oconto, Wis. 

Every Day Surgery 173 

C. C, MooRE, M.D., Philadelphia. 

Foreign Substances in the Ear for Thirty Years. . 175 


The Surgical Society of Louisville 175 


Tetanus ; Its Cause and Cure 134 














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Medical and Surgical 

No. 1900. 


Vol. LXIX— No. 5 



JOSEPH PRICE, A. M., M. D,, The Preston Retreat/ Philadelphia. 

The occasion and the peculiar auspices 
under which I appear here can scarcely 
fail to be to me somewhat embarrassing. 
I cannot avoid a feeling of inadequacy for 
a work which on account of its momentous 
importance should be well done. It may 
be claimed that all has been said; then 
what I say, I only throw in as confirma- 
tory of that which is accepted as complete. 
That all has been said and the best done 
is a shallow assumption. We are just 
beginning to talk and that but stammer- 
ingly — and as yet much of our surgery is 
bungling and blundering. We do not 
esteem the facts we have as all there are. 
We prize our advances the more for their 
promise of something better, we find in 
them prophecy of yet more splendid 
development and yet greater discoveries 
in our science ; of more originality and 
greater simplicity of method. Our 
country has given us great names to place 
beside those on the other side of the 
ocean. Yet we need to greatly multiply 
the reasons for our boasting. 

Personally we hope to avoid pretension, 
to give out only those lessons our experi- 
ences have taught us. My deductions 
will not be theoretical, but these drawn 
from actual experience. The importance 
of adopting simple and direct methods, 
those tried, tested and practiced by a 
number of successful operators, should 
influence all beginners in the choice of 
methods. The fact that A and B have 

* Lecture delivered at the ;Post Graduate Medical 
Scheol of Chicago. 

been the most successful operators, that 
their mortality has been low, that they 
complete their work at any cost, that 
serious post-operative complications have 
been of rare occurrence are facts worthy 
of serious consideration by the practically 
inexperienced. We have a valuable surgi- 
cal literature recording for us the methods 
which have withstood successfully many 
tests in the experience of our best sur- 
geons. By careful study of this literature, 
which is at easy command, there can be 
gleaned many lessons that will serve a 
good purpose in puzzling and trying cases, 
such as come to every surgeon no matter 
what his skill. 

Though we have been rapidly simplify- 
ing our somewhat ambiguous surgical 
nomenclature there is still much confu- 
sion, lack of definiteness of application in 
many of our terms. In discussing post- 
operative sequelae and some of the causes 
leading to the same, we will not concern 
ourselves as to terms used to designate 
pelvic and abdominal conditions, those 
having for us no very special clinical 
value. The endeavor will be to use such 
terms as will make our meaning clear. 
We hope we have a better understanding 
— a clearer conception of our subject — 
than we have of any dead language, the 
Latin or the Greek, that you will not need 
an English, Latin or G-reek glossary to 
get at our meaning and that our facts are 
such as can be made plain even through 
limited and imperfect English. In our 
work the sequelae of what we do is the one 


Original Articles. 

Vol. Ixix 

supreme concern. Notwithstanding the 
sequel of many procedures have been a 
fruitful source of skepticism with many, 
the gynecologist and obstetrician have 
gone on and through improved skill and 
technique have brushed away many old 
objections and obstructions; they have 
grown in the consciousness of their ability 
to deal successfully with cases which in a 
near past were allowed to suffer on with- 
out relief. We have arrived at the point 
of knowing that many women suffer from 
diseases that cannot be cured or even re- 
lieved of their severer symptoms by purely 
medical treatment; that we frequently 
meet with pathological conditions that 
medicine, massage, or electricity will not 
relieve ; that grow from bad to worse and 
that only surgery can reach; that for many 
cases there are only two avenues of relief, 
skillful surgery or death. 

Here I would mention that a great 
number of deaths are of patients where 
there has not been even a suggestion that 
surgical interference would save life. In 
many instances death comes before the phy- 
sician even recognizes the character or gra- 
vity of the trouble ; before a correct diagnosis 
is made, and again to that group classed by 
operators as hopeless when first seen, who 
are permitted to suffer on and die without 
an attempt being made or offered for ration- 
al surgical relief. Again a third group, a 
most distressing class to the surgeon, who is 
willing to give the one chance, those who 
die on^the table, or soon after the operation 
— never reacting. There is current among 
the more or less intelligent laity and the 
more or less, usually the latter, intelligent 
non-specialist and general practitioners, 
that the results in abdominal and pelvic 
surgery are either eminently successful or 
else woefully responsible for a train of 
after results in the unfortunately surviving 
patient, that render it scarcely a permis- 
sible branch of surgery unless the former 
results can be absolutely promised. Just 
why this should be is a little difficult of 
explanation unless the early history of this 
special line of work is considered, together 
with the methods of certain operators, 
with whom promises were a part of the 
means by which operation in many 
cases was obtained. In no other division, of 
either medicine or surgery, is it demanded 
of the physician that his results be abso- 
lutely certain and that he guarantee after 
immunity from all trouble allied to that 

which he undertakes to remove. Unfortu- 
nately there are some at present, possibly 
not so many as formerly, who in order to 
obtain chance for operation, were ready to 
promise everything, just as the ready 
witted politician has ofifices waiting for 
every one whose franchise shall be cast for 
him. Mrs. X, shall have no more pain, 
while Mrs. Z, shall be absolutely relieved 
of every appearance of her monthly distur- 
bance, while Mrs. Q, shall never again suf- 
fer constipation or tenesmus, and so on 
throughout the whole catalogue of diseases, 
for which operation is ever done or 
suggested. Now this was all unfair 
both to patient and operator. Operation 
is done to definitely remove certain 
diseased conditions, and to remedy 
aberrant physiological conditions incident 
thereto. Any more than this cannot be 
promised. No more than is promised in 
the treatment of every other disease. 
The physician called on to treat a case of 
typhoid, does not insure his patient in the 
event of his recovery total immunity from 
all the sequelae incident there to. Neither 
does he on taking charge of the case give 
absolute assurance of the recovery itself. 
Neither should the surgeon be required to 
do so except within the limits of his own 
experience in the conditions for which he 
is about to operate. No surgeon should 
promise recovery to his patients on the 
grounds of the results of others, unless 
his own experience is absolutely parallel 
with theirs. The beginner in abdominal 
and pelvic surgery, unless after a long 
and careful preliminary training, and un- 
less accompanied in his work by a careful 
and experienced operator, must usually 
have less perfect results than the surgeon 
of a wide and intelligent experience. I 
say intelligent experience, because there 
are operators and operators, and some with 
a wide and varied experience must never 
be looked to surpass the line of medocrity. 
An operator who in the midst of a serious 
case, looks about him, and addresses the 
spectators, " Now gentlemen if you have 
any suggestions to make, I am ready to 
receive them " is hardly the man any one 
of you would select to operate upon wife 
or mother. 

A general must be quickwitted, ready 
to modify the details of his movements to 
meet strategy of the enemy, but he must 
needs use his own wits, and not delay to 
send home for advice. Now all this you 

July 29, 1893. 

Original Articles. 


may say is foreign to the subject at hand, 
but I beg to submit, that^ post-operative 
complications and sequelae, have to do 
with all the factors casually suggested in 
these prefatory remarks. For your 
more intelligent appreciation of the same 
I shall divide them, group them, if you 
please, as I have most frequently met 
them, into three classes : 

First: Post-operative sequelae due to 
complications induced by delay in operat- 

Second : Complications induced by 
faulty work and methods. 

Third: Sequelae, which may be said 
to follow naturally any serious surgical 
procedure of the nature under considera- 

Incidentally, as following along the line 
of thought here suggested, will be con- 
sidered the ways and means best adapted 
in the light of surgical experience to 
avoid the avoidable in the way of unsatis- 
factory results in this branch of sur- 

Delay in operating is at once the bane 
and danger of all pelvic and abdominal 
surgery ; baneful to the surgeon, danger- 
ous to the patient. This is true in all 
the various conditions met in the pelvis 
and abdomen, but especially true in two 
diverse conditions, pus in the pelvis and 
in tumors of the uterus. I have long 
earnestly advocated the prompt removal of 
all puriform degenerations in the pelvis, 
and the longer and farther my experience 
grows, 1 find I have no reason to change. 
The logic that hesitates at an early 
amputation in order to save an inch or an 
ell of a leg, while thereby life may be 
risked, is only half-way foolish as com- 
pared with the procrastination that 
dawddles with puriform disease involving 
the integrity of the vital abdominal 
viscera. Pus within the pelvis is at once 
a present and a far reaching menace to 
the safety of the patient. Its extension 
is not limited geographically nor anatom- 
ically nor functionally. Pus that 
starts in the tube may burrow through 
the diaphragm, or show itself in a pul- 
monary abscess, while, an appendicitis 
may rush through like a Johnstown flood 
and assail the very vitals of the economy. 
Now while the results of retained and im- 
prisoned pus may be thus fulminant in 
their nature, they may also be insidious, 
slowly attacking the vitality of the 

sufferer, bringing on a train of evils, 
which like gossip growing with a thous- 
and tongues, gains by going and is 
dangerous apace. Pus if it is not absorbed 
is irritating and excites inflammation, 
and inflammation brings about adhesions 
among the organs surrounding the pus 
focus. So it is that an inflammation 
starting in one organ often necessitates 
surgical interference with another entirely 
distinct from it physiologically and dis- 
tinct from it anatomatically. Bowel ad- 
hesions are most common in delayed tubal 
operations, and where the puriform de- 
generation has gone beyond a certain time 
the bowel instead of being adherent is 
often really gangrenous, and its treatment 
brings into the field the most delicate and 
painstaking intestinal surgery. Now in 
these cases we must'look upon the intestinal 
surgery both in the light of operative comp- 
lication and of being indirectly the cause of 
post-operative complications and sequelae. 
Its presence as a complication of the 
original operation for the removal of the 
pus tube is incident to delay in the 
original operation, and is a necessity on 
account of this delay. Without it the 
operation as at present necessitated, would 
be a failure or a very bleak success. But 
if on account of this necessary bowel 
surgery there is after trouble brought on 
by stenosis and diminished calibre of the 
gut, is the surgeon or abdominal surgery 
responsible for such result however un- 
fortunate it may be ? Can such sequelae be 
for an instant considered argument 
against either the results or legitimacy of 
abdominal work, or against the perfection 
of its methods, apart from preceding 
calamitous neglect ? I think the good 
judgment of all must decide that in such 
cases surgery has not had its chance. And 
so, if after a case has been neglected until 
a general peritonitis supervenes after a 
long period of pus-infection, and conse- 
quent loss of vitality in all structure, so 
that, as often happens, the stitches in the 
abdominal wall will scarcely hold and 
there is a consequent necessity for the 
whole incision to heal by granulation, can 
it be charged to surgery that its methods 
have been faulty or inefficient? Certainly 
not. Whatever after complications arise, 
adhesions, hernia, fistulae or else of this 
uncanny clan, must be laid directly at the 
door of the bad logic and poor wisdom of 
those to whom the delay is attributable. 


Original Articles. 

Vol. Ixix 

The same reasoning, and possibly with 
even a greater scope in the possibility of 
the complications, will apply to neglected 
cases of uterine tumor. These are apt, as 
you all know, to be tampered with by 
every agency under the sun. Each and 
every dilly-dallier is busy seeking methods, 
and modifications and refinements of 
dilettante- quixotism in order the more 
to steer shy of the true surgical treatment 
of which they have a mere smattering of 
information and this theoretical — not 
practical. While these empirical devices 
are being put into practice the disease 
travels on apace, the tumor increases and 
trespasses upon other important organs, 
interferes with their integrity by pressure, 
contracts adhesions with bladder, intes- 
tines and omentum, and, so the disease 
steadily progresses, the tumor increasing in 
size and irregularity, which with the in- 
creased density and thickness of the ad- 
hesions makes its removal a daily increas- 
ing difl&culty. This is the more likely 
to be true if tampered with by electricity, 
with or without puncture — all the more 
if puncture is used at all. 

It will be understood at a glance that the 
reasoning that applies to the two distinct 
affections here alluded to, must surgically 
apply to all diseases of the pelvis and 
abdomen. This is probably true of appen- 
dicitis, than which there is not a more 
neglected disease, nor one in which so 
much is "trusted to nature. ^"^ Delay here is 
the very essence of danger, and often puts 
us once and for all outside the possible 
chance of relieving a patient. It is un- 
necessary for me to further insist upon 
this fact here. Both your instructors and 
your instruction are en courant with all 
that is best on the subject. Under this 
head it is only necessary to again insist 
that whatever is logic in one set of ab- 
dominal diseases, from a surgical stand- 
point, is logic in all, and that early surgery 
soundly applied, is the open sesame to all 
success in their treatment. 

The second series of complications I have 
classed as those due to faulty work or meth- 
ods. Under this head I have most frequent- 
ly found adhesions about the incision or in- 
deed throughout the abdomen and pelvis, 
due to the presence of irrigating fluids. 
It used to be thought that chemicals were 
the highway to cleanliness, that an other- 
wise dirty surgeon could be clean if he 
had a basinf ull of bichloride solution at his 

side — a sort of dirt "Taboo," so to speak. 
This had its effect in the complications 
under notice, and the banishment of this 
harmful superfluity has worked good in 
many ways, first by taking away a frequent 
cause for re-operation, and second, in 
teaching operators that cleanliness is an 
essential, inherent trait of the man and 
cannot be grafted on him by chemicals. 

While considering adhesions, it may be 
well to refer to their imperfect handling- 
as a very pregnant cause of unsatisfactory 
results in pelvic surgery. When they 
exist they are not to be attacked wildly 
and rudely, but are to be broken up care- 
fully, and each step guarded by careful 
inspection. If by chance the gut is torn 
through, it is at once to be mended, all 
else being for the time suspended unless 
it is the stoppage of hemorrhage. Tears 
in the omentum are to be dealt with after 
the same manner, otherwise pitfalls are 
left for the unwary intestine, whereby to 
strangulate itself. All peritoneal destruc- 
tion is to be avoided, and any portion of 
surface operated upon that can be covered 
with peritoneum is a direct safeguard 
against adhesion ; this is especially true of 
large fleshy pedicles. In the removal of 
diseased organs it is necessary carefully _ 
to break up not only the adhesions 
existing between the parts removed 
and those remaining, but also those 
between all remaining parts otherwise 
healthy. Failure to do this is a fertile 
cause of bowel obstruction, resulting 
fatally in cases that would otherwise 

Coming next in order as a fer- 
tile source of mischief is the faulty 
handling of hemorrhage. At the bottom of 
much hemorrhage is the reprehensible use 
of cat-gut. The use of this agent ought to be 
avoided ; except for the very smallest vessels 
it is not so safe as silk, and the latter has 
too much to recommend it, too many suc- 
cesses on its side to be theoretically argued 
out of sight. The careful tying of every 
bleeding vessel as it is met, and of pedicles 
in portions small enough to secure perfect 
stricture, with sufficient button, to pre- 
vent slipping, will give security against 
hemorrhage as it most freuqently occurs. 
Just here I will memtion a method or 
rather a procedure by which all surgery, 
especially that of hemorrhage, is 
presumably made easy. I refer to 
the Trendelenburg position. This was 

July 29, 1893. 

Original Articles 


originally invented for the performance of 
suprapubic cystotomy. Those of you who 
have seen this operation know just how 
much need there is here of the Trendelen- 
burg position, and in my opinion there is 
but little more use for it anywhere else. 
In all operations in which hemorrhage is 
likely to occur by oozing and indirect 
leakage it is a positive disadvantage. The 
patient is stood nearly on her head, and 
the natural gravity of the blood reversed. 
Now this together with a weakened circula- 
tion and the presence of surgical shock, 
will give apparently a dry field of operation, 
but when the natural recumbent position 
is assumed it will at once become prone to 
oozing and leakage which may soon be- 
come a serious matter. All oozing must 
be controlled and any step which veils or 
conceals its presence is a menace to the 
safety of the patient. 

In this connection we may profitably 
consider improper drainage as a cause of 
serious complication after operation. 

Drainage is well recognized as a surgical 
necessity in operations of all kinds. 
Under certain conditions its employment 
is not disputed or questioned, except in 
the abdominal cavity. Why this is so is 
not always easy to explain. In fact it is 
probably best not to attempt to explain 
every vagary that comet-like flits across 
the unsettled minds of many following 
the plough in the furrow of abdominal sur- 
gery. It is enough to carefully listen to the 
arguments on each side, weigh them well, 
see wherein is contained the least fancy 
and the most fact and follow the lines of 
presumptive safety. Much of the dis- 
satisfaction over drainage is the result of 
crude methods and faulty care of the 
tube, and indeed of the patient. Most of 
those now condemning drainage have 
vacillated between one method and another 
and finally, without having gotten satisfac- 
tion out of any method, they condemn 
all. Gauze, lampwick, bone tubes, new 
devices to keep the tube clean, all have 
failed, and like King Solmon after he had 
gone the rounds, they cry, "Vanity of 
vanities, all is vanity." The proper way 
to apply any method is to study the end 
to be attained, and then use means to 
accomplish this end. To remove acci- 
dental debris, irritating or accumulating 
fluids there is nothing that so well answers 
as the small glass drainage tube reinforced 
with the long-nozzled syringe. All other 

device is unnecessary. Gauze is a good 
primary but a poor secondary drain. It 
will not discharge lymph, nor will it insure 
the non-disturbance of the parts on its 
removal as is afforded by the simple glass 
tube. It like wise promotes adhesions, and 
these are the factors necessitating much 
after-surgery in the abdomen. All foreign 
matter introduced at the time of operation 
must come under the head of irritants 
and this is true of the drainage tube ; 
the more so the longer it remains 
unless it is absolutely clean, and 
kept clean or in fact unable to get 
dirty. The improper handling of 
the drainage tube, its shifting or its rude 
handling may make it, in careless or un- 
skillful hands, a source of danger and dis, 
comfort to the patient. This is, however- 
no argument against its proper use, and 
the operator who gets bowel fistulae from 
it simply confesses that he has placed it 
improperly, while he who lays ventral 
hernia to it as a prime factor forgets that 
hernise rarely appear in the lower angle of 
the wound where the tubes should always 
be placed. 

Under the head of foreign bodies as a 
cause of mischief it is necessary to class 
big and unnecessary ligatures. Many 
small vessels can be secured by torsion 
whereby tying is rendered unnecessary. 
When this can be safely done it is by far 
preferable to the use of multitudes of 
ligatures. Big, heavy, braided silk is apt 
to cause trouble by non-absorption 
and by making a focus for suppuration. 
Hence it is the rule to avoid ligatures 
heavy past the absolute necessity of each 
individual case, and to apply as few as pos- 

Big ligatures probably are oftener 
the cause of abdominal fistulse than any 
other factor, unless it be in those of a 
fecal nature. These latter are caused by 
failure to mend weakened spots in the 
gut, or by badly placed drainage tubes. 

I have neglected to consider one point in 
reference to drainage and to do this I 
shall go back for a little. I mean the 
consideration of the after condition of the 
patient. She is always quiet except in 
the rarest cases; her recovery is non-fe- 
brile, her tongue is clean, her secretions 
normal. I am speaking of course of cases 
in which there have been pus and adhe- 
sions. In simple cases this condition of 
affairs ought always to obtain. This is in 


Original Articles. 

Vol. Ixix 

marked contrast with cases in which, 
under similar conditions of operation 
drainage is not used. The contrast is as 
marked as that laid down in the books be- 
tween concussion and compression of the 
brain. The quioblers cry your operation 
has not been clean or you would not need 
drainage ; and again, before this alarm has 
died away, another investigating army ex- 
plain away the use of the tube because it 
infects the stump and carries millions of 
microbes into the abdomen. Here is at 
once a confession and a plea. First, they 
do not know when or how to use the tube, 
and second, they explain it away on the 
ground of its causing what on the first 
hand they confess is a necessity for its 
employment. Such argument needs but 
little attention. 

Passing on I shall class as imperfect sur- 
gery all that leaves behind removable 
diseased organs or conditions. Under this 
head must be placed vaginal puncture for 
pus in the tubes, and the vaginal removal 
of diseased organs. Both of these opera- 
tions are unjustifiable : first, because they 
are incomplete, and second, because they 
do not allow the operator to manipulate 
freely enough to entirely relieve the patient 
either of her danger or discomfort. Pus 
tubes are not a simple condition, but are 
complicated with adhesions and, therefore, 
in order to deal with these all the vantage 
ground of operative position must be 
sought. This is impossible in the vaginal 
operation. Adhesions in pelvic disease are 
often the|bulk of all the trouble, and hence 
they must not be left. Abscess of the 
pelvic organs is rarely a simple sac, and, 
therefore, cannot be cured by mere punc- 
ture. That once in a while such a case 
is met is no argument by which a 
general method is to be laid down. 
Enucleation and removal, drainage and 
freeing adhesions is the only proper mode 
of procedure. 

A word now as to conditions 
following operation, traceable often 
to bad care of the patient or to improper 
surgical procedures. At the head of the 
list is ventral hernise. Many patients are 
directly responsible for their own condition 
in this respect. Too early rising, too 
early laying aside the bandage, and fool- 
ish physical exertion, such as dancing, rid- 
ing and the like, frequently bring on the 
condition for which the surgeon is in no 
way responsible. But on the other hand, 

over-anxiety of the surgeon to get an 
empty bed in his hospital or to chronicle 
a wonderful recovery, are among these 
secondary, non- surgical causes of this acci- 
dent. The incision and its closure are to be 
carefully considered in this accident. A 
short incision, with the stitches uniformly 
introduced on either side so as to preclude 
turning in of the skin edges is 
this the best safeguard against 
accident. Personally I do not agree 
with those who introduce layer after layer 
of sutures. Again it is a recognized fact 
that incision through one of the recti, is 
less apt to cause hernia than linear 
incision. I submit that a series of care- 
fully watched operations on this line would 
be of the greatest interest. 

I have now gone over some of the chief 
causes of accident and complication in 
abdominal work, enough at least to give 
you food for thought, in the lines of real 
experiences without any theory whatever, 
and it remains for me at this time only 
to refer briefly to some of the after con- 
ditions of operation for this set of 
diseases, which naturally are to be ex- 
pected. First are the phenomena attend- 
ing the removal of the appendages. All 
women are not affected alike. Some en- 
dure their removal with immunity from 
discomfort, while others are for a long 
time annoyed with the phenomena attend- 
ing the menopause. Hence it is not safe 
at once to promise perfect comfort to 
these patients, nor indeed to tell them 
even that the menopause will infallibly at 
once ensue. Some women persist in 
periodic hemorrhages, some cease at once, 
others continue more regularly than ever. 
The why of all this is not clear. Again 
in chronic cases, where the pain and dis- 
comfort has lasted long the recovery is 
often more or less tedious. Pain has be- 
come engrafted upon the organism and 
time only will remove it. To such 
patients must be given encouragement to 
await patiently the gradual restoration 
to health, just as they would expect to do 
in the external surgery of the body. 
Miracles are not to be expected here, 
neither is it fair to promise them. The 
same careful consideration of all the prob- 
abilities of the case should here be 
made; the same honest expectation of 
life and health afforded; no more, no 

The manner, matter and methods of 

July 29, 1893. 

Clinical Lectures. 


abdominal surgery have to deal with hu- 
manity in channels that most concern it, 
and hence they afford scope for the widest 
humanitarianism, the truest philanthropy, 
the bravest hearts. 

Our profession is adjusting itself to the 
spirit of the period ; to its spirit of enter- 
prise, research and invention. We now 
come to Chicago as to the world's great 
school, to this great city of the great 
West, which, in little more than half a 
century has become the second city of our 
country in population, and very strongly 
second in commercial importance; the 
enterprise of whose people could not be 
burnt out with the burning over of more 
than two thousand acres of the city's area. 
And here within its corporate borders has 
been built as by magic the " White City," 
in fitting celebration of the event that 
gave to mankind a new world. And thick 
peopled is this " White City,'' with those 
from our many states and from over the 
seas, all moving bewildered about what is 
so vast in suggestion, so immense with 

what has been done, is doing and is 
promised. Its walls of themselves make 
all the world marvel at the creations of 
American genius and enterprise. Amid 
these creations we stand amazed by the 
beautiful designing of the architect, by 
the studied, skilled, cunning work of the 
mechanic ; by that beauty, proportion and 
strength which has been evolved from 
rude and uncouth conditions, all illustra- 
tive of the manual dexterity, the 
strength, skill and wisdom of master 
workmen. As we note the achievements 
of mechanical and industrial art we feel 
the stronger assurance of the immense 
possibilities of our own art, — we do not 
look for results to peculiar inspiration 
but to hard work. Our aim should 
be to make our art the supreme one, 
as it is the one that most intimately 
concerns human physical well being, the 
need to be workmen, trained to surgical 
dexterity, to greater certainty and accuracy 
than that which directs the thought and 
hand of the sculptor. 



ROSWBLL PARK, A. M., M. D., Buffalo, N. Y. 

Six weeks ago I operated on this boy 
for painful flat-foot, chiseling off the head 
of the astragalus on each side, so as to al- 
low the feet to become slightly inverted 
and arched. If you will notice the im- 
pressions of bare feet you will see that we 
naturally walk on the outer side of the 
foot. This boy, on the other hand, was 
walking with everted feet, bearing his 
weight on the inner portion of the soles. 
After the operation the feet were dressed 
antiseptically and encased in plaster-of- 
Paris, which remained on five weeks. 
The patient is about to leave the hospital, 
the wounds are entirely healed and the 
shape of the feet is all that can be desired. 
It will be a month or six weeks longer be- 
fore the tissues will have become firm 
enough to permit the child to walk. If, 
even at the end of that time, there is any 
tendency to stretch and allow the foot to 

regain its malposition, it will be necessary 
to apply a metal brace, suitably moulded 
to the lower surface of the foot, and then 
bending at a right angle and reaching up 
the side of the leg. 

The first operative case is that of a girl 
of seventeen, with a tumor in the middle 
of the neck, which is probably a small 
goitre. In reply to questions which were 
not leading, she tells me that the tumor 
was first noticed at the time of puberty, 
there being at that time a small enlarge- 
ment in the middle of the thyroid body. 
At each menstrual period, it has grown a 
little, receding somewhat before the next 
period but gradually becoming larger. 
This history is an illustration of the mys- 
terious sympathy existing between the 
thyroid and the sexual organs of the fe- 
male, a sympathy that is manifested in 


Clinical Lectures. 

Vol. Ixix 

the growth of the thyroid during preg- 
nancy. In some ill-understood way, the 
thyroid has something to do with the 
elaboration of the blood corpuscles, and 
when we remember that during pregnancy 
and at the menstrual periods there are 
calls for the renewal of the blood and an 
increase in its elements, we may under- 
stand somewhat the connection between 
the enlargement of the thyroid and the 
state of the sexual organs. Sometimes 
after delivery the enlargement of the thy- 
roid retrogrades; sometimes it does not. 
I have now under care two private 
patients who have had three children, 
and each pregnancy has caused an en- 
largement of the thyroid, both lobes being 
enlarged, though not symmetrically. In 
the present instance, it is the central por- 
tion of the thyroid body — I do not like 
to call it a gland — which seems to be en- 
larged. The girl came to me a little while 
ago asking what could be done, and I told 
her there were three ways in which the 
trouble could be treated: first, by applying 
or administering drugs, a method which 
would do little or no good; second, by the 
use of electricity, which sometimes helps 
the condition a little but which is always 
slow and often futile ; third, by surgical 
interference which is immediate and radi- 
cal in its relief. Although I said nothing 
to her to urge operation, she at once 
jumped at the chance, and decided to have 
the mass removed. If the tumor involved 
the whole thyroid, I should be averse to 
operating, for it is known that the com- 
plete extirpation of the thyroid is some- 
times followed by a peculiar vital depres- 
sion and imbecility to which the name 
cachexia strumipriva has been applied. 
But we have learned by experiments that 
a portion of the thyroid, even four-fifths, 
may be removed without danger, the re- 
maining structure being sufficient to per- 
form the function of the whole body. 

This tumor is probably cystic. 

[The tumor was exposed by a median 
line incision and found to be pedunculated. 
It was ligated with cat-gut and cut ofi 
from the small pedicle ; the external suture 
was of the subcutaneous, continuous kind, 
in order to avoid cross-marks in the scar. 
The bandage over the antiseptic dressing 
was extended below the axillae in order 
to prevent disarrangement.] 

The next patient is a decrepit old man. 

somewhat emaciated, who has suffered for 
at least two years with such bladder symp- 
toms as frequent micturition, with direct 
and referred pains. He has been compelled 
to give up his occupation and, as he feels 
better in the recumbent posture, to spend 
most of his time on the lounge. His 
symptoms point either to enlarged prostate 
or to a calculus, or both, with consequent 
irritability of the bladder. He has been 
sent here from quite a distance, one 
of his attending physicians having 
touched a stone with a sound. On 
my first examination with ordinary manip- 
ulations I failed to discover a stone, and 
even the assistance of the finger in the 
rectum did not avail. I then drew off the 
urine and filled his bladder with a boric 
acid solution till he complained of disten- 
tion, and then passing the sound I touched 
the stone. A difficulty in introducing 
the sound and the rectal examination 
showed also that there was an enlarged 
prostate, and, through the patient had 
just emptied the bladder as he supposed, 
nearly half a pint of residual urine was 
drawn off by the catheter, having been 
retained on account of the prostatic en- 
largement. I want to impress on you the 
fact that a stone which eludes ordinary 
searching may be detected by first distend- 
ing the bladder. 

Two questions arise, what is the 
character of the stone, and what is the best 
means of removing it ? The urine is acid 
now and although the nucleus of the stone 
may be phosphatic, the shell at least is 
probably composed of uric acid. Uric 
acid calculi are always hard and difficult ta 
crush, and an attempt to remove the stone 
in fragments through the urethra would be 
prolonged to a hazardous degree. I found 
also at my examination that the end of 
the sound caught in one or two places in 
the interior of the bladder, showing that 
there are pockets in which some of the 
fragments of the stone might lodge and 
form nuclei for other calculi. We must 
have recourse then to a cutting operation, 
and I have decided to enter the bladder 
by the supra-pubic roate, which is not the 
quickest but which gives the best oppor- 
tunity for exploration. The perineal sec- 
tion to a man used to the manoeuvre 
is a rapid and may be made a brilliant - 
operation, but it may be difficult to find 
the stone afterward. The supra-pubic 
section takes a few minutes while the 

July 29, 1893. 

Clinical Lectures, 


perineal requires only a few seconds, but 
by choosing the former, I run no risk of 
injuring the prostrate, and I can find the 
calculus more readily and extract it entire. 
The supra-pubic method or sectio alta^ 
was in vogue many centuries ago, but was 
abandoned for the perineal operation and 
has been revived only during the present 
generation. By many surgeons it is now 
used almost to the exculsion of the peri- 
neal operation. I do not believe however, 
that any one method is of intrinsic 
superiority, and think that each particular 
case should be studied and the decision 
made as to the preferable method in ac- 
cordance with its special features. 

The shaving of the field of operation 
has been deferred till anaesthesia is com- 
plete, in order not to alarm the patient 
who is quite timid. The urine is now 
withdrawn and the bladder filled with a 
boric acid solution. The attempt to pass 
a regular stone searcher with an abrupt 
curve, meets with considerable difficulty, 
but this large steel sound passes easily 
and you can hear the click of the instru- 
ment against the stone, which seems to be 
a large one. With the bladder distended, 
the peritoneal covering is raised some 
distance above the pubis, so that it is easy 
to enter the bladder without penetrating 
into the peritoneal cavity. The longi- 
tudinal incision in this instance, fails to 
encounter a plexus 6i veins which is often 
found in the prevesical space, and the 
hemorrhage is not annoying. The handle 
of the sound is now depressed so as to 
present the other end as a guide for the 
incision into the bladder, but before the 
knife is used I will pass two heavy cat-gut 
sutures through the bladder wall and hold 
their ends with hsemostats till we need to 
tie them. It would be more difficult to 
get the threads in a position with the 
bladder empty and collapsed. A con- 
siderable gush of fluid follows the pene- 
tration of the knife, and on inserting my 
fingers I find four calculi, which you see 
are hard and have the characteristic ap- 
pearance of uric acid. The prostate is so 
much enlarged as almost to tempt me to 
remove a part of it, but the patient is old 
and feeble, and I do not feel justified in 
adding to the necessary shock of opera- 
tion. Behind the prostate is a pocket in 
which residual urine has remained and 
caused so much discomfort and in it I find 
a fifth calculus. 

After thus cleaning out and washing 
the bladder with boric solution, I sew the 
margins of the wound up to those of the 
skin wound with a single suture on each 
side, preferring this to closing the in- 
cision, partly from a desire for the in- 
creased security of this method, and 
partly because his bladder needs now rest 
and free drainage, both of which can be 
thus better secured. A double catheter is 
passed into the viscus so far that its lower 
end projects down to the pocket behind 
the prostate ; it is held in this position by 
a silk suture passed through the skin. 
Iodoform gauze is placed around it and in 
the wound. A large mat of dressing, per- 
forated for the passage of the tube, is ap- 
plied over the lower part of the belly, 
held in place by adhesive strips and a 
double spica bandage, and the patient put 
in bed. 

[He made a rapid recovery]. 

The next case is rather obscure, and I 
am unable to tell you in advance either 
its exact nature or the method of opera- 
tion that will be followed. The patient 
is a man about fifty, who presents enlarge- 
ments under and apparently attached to 
the lower jaw bone. On one side the 
mass is rather soft and small, on the other 
it is hard and nodular and considerably 
larger. It is eight months since the trou- 
ble was first noticed and in that time the 
masses have grown so as to interfere with 
breathing and swallowing, though they are 
not very prominent externally. The pa- 
tient has given to one member of the staff 
an account of syphilis, and has denied all 
venereal history in his statements to 
another. It was decided to give him for 
a time the benefit of the doubt and to 
treat him upon a tentative diagnosis of 
syphilis. It must be borne in mind, 
however, that the venereal history is con- 
tradictory and the objective evidences not 
conclusive. Moreover, the mass has con- 
tinued to grow in spite of anti-syphilitic 
treatment and the location is an unusual 
one for the syphilitic gumma. We must 
also consider the possibility of the growth 
being sarcomatous and, for the sake of 
completeness, we might think of actino- 
mycosis. Such a case is rarely seen in 
the human being but the patient is a 
common laborer and he might have been 
exposed to the fungus. Acting on the 
supposition that the tumor is a gumma, 



Vol. Ixix 

breaking down in tlie interior, I have 
made preparations to open and curette it 
and to cauterize the walls of the cavity. 
In this way the patient would be relieved 
of actual pressure symptoms and with 
general treatment would probably recover 
so that the immediate removal of the en- 
tire mass would be unnecessary. 

The case is at least a lesson to you that 
an exact diagnosis before the removal and 
examination of a growth is often extremely 
difficult, if not sometimes impossible. 
But I want you to learn an even more im- 
portant lesson, namely, that in some in- 
stances an operator can not tell before- 
hand just how he will proceed and each 
step in the operation may depend upon 
some unexpected development, so that the 
prudent surgeon must be prepared for 
emergencies as well as for an anticipated 
line of action. You see among other in- 
struments in the tray bone-forceps and 
the chain saw, so that if we have to deal 
with a malignant growth affecting the 
maxilla, the operation may not be delayed. 
These instruments, however, will probab- 
ly not be needed. 

Partly for diagnostic purposes I shall 
attack the smaller and softer mass first. 

On opening into it I find that its interior 
seems to have undergone cystic rather 
than suppurative degeneration, and this 
fact throws doubt on the diagnosis of spe- 
cific trouble. Before attempting to dis- 
pose of this growth, I will open into the 
larger tumor to see if both are of the 
same nature. This tumor cuts, not like 
a gumma, but like cartilage and, in spite 
of its size, I find no breaking down in its 
center, whereas a gumma of this size 
would be almost certain to contain a 
cavity. We must abandon the diagnosis 
of syphilitic gumma and proceed to eradi- 
cate a sarcomatous mass which involves 
the lower jaw. The precaution of having 
in readiness the bone- saw and forceps was 
a wise one, for I shall have to remove a 
portion of the maxilla between the angle 
and the symphysis, at least on the side of 
the larger growth. 

[Operation proceeded without diffi- 
culty, and the patient^s condition was for 
the time being very much improved. 
But later a very slow recurrence with in- 
filtration was observed, and further opera- 
tion was deemed inadvisable. He went 
to an adjoining alms-house and finally 
disappeared from observation.] 



CHARLES ZIMMERMANN, M. D.,« Milwaukee, Wisconsin. 

In the last few years quite a number of 
cases have come under my observation in 
which the examination of the eyes, espec- 
ially with the ophthalmoscope, revealed 
pathological changes of the visual organ 
which gave the first hints of an affection 
of the central nervous system and proved 
of great value in determining the diagno- 
sis of a brain disease. They thus belong 
to a department of medicine in which 
the fields of the general practitioner and 
of the oculist border on each other, and 
in which both ought to be interested 

The reason for the frequent association 
of ocular affections with those of the 

■-'•Ophtlialinic and Aural Surgeon to St. Mary's and 
Emergency Hospitals. 

brain will at once become apparent if we 
remember what a very large extent of the 
latter is placed in relation to the eye. 
This may advantageously be looked at 
from four different points of view : first, 
the developmental ; secondly^ the anatomi- 
cal relation, inasmuch as the optic fibres 
from the optic foramen to the visual cen- 
tre are situated within the cranial cavity ; 
thirdly^ the connection by the ocular, the 
^ fifth,' the facial and sympathetic nerves ; 
and, fourthly^ the common causes for as- 
sociated diseases of both organs. 

Consider the eye developmentally, and 
the retina and optic nerve are to be 
regarded as a prolongation of the brain. 
In a very early period of foetal life, when 
the anterior portion of the medulary tube 

July 29, 1893. 



has been transformed into the three cere- 
bral vesicles, from the foremost of these 
a new vesicle, the primary ocular, grows 
out, remaining connected with it by a 
hoHou^ tube — the first trace of the optic 
nerve. From the cell-layer covering its 
pole the lens develops, pushing its wall 
inwards, so that the hollow sphere is con- 
verted into a shell consisting of two layers 
— the secondary ocular vesicle. Its inner 
sheath becomes later on the retina and 
its outer layer the pigment epithelium. 
In this way the retina and optic nerve are 
advanced or external parts of the brain. 
Therefore it seems quite natural that 
pathological changes in the intracranial 
portions of the brain, that is in the brain 
proper, may be propagated to the external 
parts, that is retina and optic nerve, and 
that these may show alterations indicating 
associated or analogous affections of the 
encephalic parts. The three sheaths of 
the optic nerve are a direct continuation 
of the three meninges, the dura mater, 
arachnoid and pia mater, separated by the 
subdural and subarachnoidal spaces, which 
communicate with the identical cerebral 
spaces. The subdural space of the optic 
nerve forms in the normal eye only a very 
narrow fissure, whereas the larger sub- 
arachnoidal represents the so called in- 
tervaginal space. The spaces are lined 
with endothelium and are to be con- 
sidered as lymph- channels of the eye. 
Schwalbe, Quincke, Deutschmann and 
Gifford demonstrated that in these spaces 
there is a lymph current from the brain to 
the eye. 

We must be familar with these facts in 
discussing one of the most important 
ophthalmoscopic symptoms in brain dis- 
seases, the optic neuritis usually called 
choked disc or papillitis. In this disease 
the optic disc presents the aspect of con- 
gestion with oedema, increased redness, 
blurred edges, radiating striation of whitish 
nerve fibres spreading into the retina, and 
sometimes small hemorrhages with general 
cloudiness. The arteries are concealed at 
their emergence and narrowed. The 
veins are dilated, are tortuous, look dark 
and as if cut into pieces. The swelling 
of the disc, which in some cases may be- 
come so intense that it forms a fungi-form 
tumor, its sides overhanging the retina, 
is recognized by the relative displacement 
of different parts by parallactic movements 
of the lens, and, in the direct method of 

ophthalmoscopical examination, by its 
changed focus in comparison to the retina 
amounting sometimes to four diopteries. 
The adjacent portion of the retina may 
take part in the inflammation and present 
areas of opacity and hemorrhages. If it 
extends to the macula, the familiar stellate 
form of white streaks and dots, as seen in 
renal disease, appears, caused by a degen- 
eration of the radiating fibres of the fovea 

The pathological anatomy of papillitis 
consists of a swelling of the disc, visible 
even to the naked eye, rising from two 
to three millimetres above the level of the 
choroid. It is caused by dilatation of the 
blood vessels, oedema, proliferation of nu- 
clei, emigration of leucocytes and hyper- 
trophy of nerve fibres. The nuclei may 
form a thick layer around the blood vessels 
and the nerve fibres. The coats of the 
blood vessels are thickened by nucleated 
tissue, the nerve fibres show varicose en- 
largements from an accumulation of fatty 
globules which are the products of a de- 
generation of myelin. Sometimes colloid 
corpuscles are found between them. The 
nuclear layers of the retina are thickened 
and the fibres of Miiller hypertrophied. 
The. trunk of the optic nerve shows 
changes of an inflammatory character, 
sometimes as far back as the chiasm, in- 
crease of nuclei, distension of vessels and 
thickening of its trabecule. The sheath 
is mostly distended, reaching sometimes 
such a considerable degree that it forms 
an ampulla close behind the globe. The 
development of papillitis may take place, 
in the cases of rapid course, in two to 
three weeks, remain at its acme two 
weeks and then subside. This happens 
mostly when depending upon a cerebral 
affection of transient, and especially of 
syphilitic character. 

But in other cases optic neuritis may 
be very chronic; for instance, when caused 
by a cerebral tumor which progresses very 
slowly. Then it may last for weeks and 
months, and then subside and pass 
into atrophy. The papillitic atrophy is 
brought about by the shrinking and 
strangulating influence of the connective 
tissue into which the newly-formed in- 
flammatory products have been trans- 
formed. By its contraction the vessels 
become narrowed and may be partly con- 
cealed. The disc itself assumes a greyish 
tint, the lamina cribrosa remaining 



Vol. Ixix 

perfectly veiled. Its edge is blurred, 
although in some cases it may become so 
sharply defined that it is very diflB.cult to 
trace the atrophy to its origin. 

One of the strangest peculiarities in 
some cases of papillitis of much marked 
pathological change, is the integrity of 
sight, visual field and color perception. In 
others it is impaired or lost. Pain in the 
eye is very rare, and if in the head, is 
due to intracranial affection. The impair- 
ment of sight comes on rapidly or slowly, 
never suddenly. Vision may fail in the 
course of a few days. The field of vision 
is affected in various ways. The mechan- 
ism by which sight is impaired is very 
important, especially in regard to the 
prognosis. In intracranial disease the 
loss of sight may be caused by the intra- 
ocular changes of the papillitis or by an 
affection of the visual fibres or centres. A 
sudden blindness in optic neuritis comes 
on only when associated with mischief far- 
ther back in the optic path. The ambly- 
opia caused by the inflammatory process 
during its acme may nearly disappear as 
the inflammation subsides, but again be 
renewed by the subsequent contraction of 
the connective tissue. 

Even after the papillitis is healed with 
restoration of vision, this may be lost en- 
tirely from an affection of the optic fibres 
within the cranium and without fresh 
ophthalmoscopic changes. Thus the dis- 
crepancy between the affection of sight 
and the course of papillitis indicates re- 
tro-ocular affections. Intracranial diseases 
are the most common causes, — tumor, 
meningitis, abscess, hydatid disease and 
softening of the brain. 

Cerebral tumor ranks highest in the 
etiology of papillitis, which is the ocular 
lesion characteristic of it. According to 
Gowers, neuritis occurs in about four- 
fifths of the cases of tumor. Annuskeand 
Reich collected 88 cases with ophthalmo- 
scopic examination and autopsy, and found 
that in only five per cent, there was no 
ophthalmoscopic change. 

Glioma, sarcoma, tubercle and syphiloma 
are usually associated with optic neuritis. 
But this has no peculiar features enabling 
us to make a diagnosis in regard to the 
nature, position or size of the tumor, 
since it was found to be absent in some 
cases of glioma, which invaded the 
brain substance only, not increasing its 
bulk. . 

The mechanism by which optic neuri- 
tis is induced by encephalic disease has 
been explained by various theories. Von 
Grsefe assumed that the increased intra- 
cranial pressure caused an impediment to 
the return of blood from the eye to the 
cavernous sinus, thus leading to hyper- 
8emia and dilatation of the central retinal 
vein. This, however, did not explain the 
origin of infiammation. In addition, its pre- 
sumption was not anatomically correct, in 
that the cavernous sinus is assumed to be 
the only outlet for the central retinal vein. 
Sesemann (in 1869) demonstrated that 
this opens either into the superior oph- 
thalmic vein or directly into the sinus af- 
ter anastomosing with the superior oph- 
thalmic by large branches. The superior 
ophthalmic communicates partly with the 
sinus, but empties by far the greatest por- 
tion of its blood through the angular into 
the anterior facial vein, which will at once 
relieve the affect of intracranial pressure 
upon the cavernous sinus. 

Manz and Schmidt called attention to 
the frequently observed distension of the 
optic sheaths in papillitis, caused by cere- 
bro-spinal fluid forced into the subvagin- 
al space by the intracranial pressure, 
which might produce papillitis by the 
compression of the optic nerve and its 
vessels. In many post-mortem examina- 
tions of cases of choked disc however, 
this distension, or hydrops of the sheaths, 
was not found at all. Leber, and later 
Scimemi, attributed to the pathogenic 
material in this fluid the exciting cause of 
neuritis. Deutschmann (1887), by recent 
experimental investigations, came to re- 
sults in favor of Leber's opinion. He in- 
jected agar-agar, stained with india-ink, 
into the subvaginal space of the rabbits 
eye, either directly or through the sub- 
dural space of the brain. When he pro- 
ceeded aseptically, he found no choked 
disc even in those cases in which, after 
forced injections, the post-mortem exam- 
ination showed a layer of black agar-agar, 
one-half to one millimeter thick, covering 
the whole surface of the brain and so com- 
pletely filling the subvaginal space that tbe 
ophthalmoscope revealed a black ring 
around the disc. If he injected agar-agar 
with an infusion of staphylococci into the 
optic sheath, or tuberculous pus into the 
cranial cavity, the typical picture of 
choked disc was obtained. In all these 
cases infiammatory changes of the papilla 

July 29, 1893. 



existed ; never compression of the vessels. 
He thus comes to the conclusion that, in 
man, mere increase of pressure does not 
cause choked disc. This follows only 
vs^hen pathogenic matter, of either chemical 
or parasitic nature, enters the optic sheath 
in the cerebro- spinal fluid. In cerebral 
tumor, the pathogenic material is produced 
by the metabolism in the tumor. The 
increase of the intracranial pressure comes 
only so far into consideration as it favors 
the entrance of the pathogenic material 
into the optic vagina. Zellweger (1887) 
came to the same experimental results 
with injections of sterilized emulsion of 
cinnabar. Furstner (1889), from path- 
ological examination, infers that, by 
changes in the optic sheaths and by the 
perineuritis which he found, impediments 
arise to the lymph circulation, especially 
its outflow, which entail a process of swell- 
ing and proliferation and later on destruc- 
tion of the nervous substance. Benedict 
ascribed it to the vaso-motor nerves. 
Hughlings Jackson and Galezowski con- 
sider the decending optic neuritis as a 
propagation of the inflammation of the 

From all these observations it seems to 
be most probable that the papillitis de- 
pendent upon intracranial diseases origin- 
ates in a descending inflammation of the 
optic nerve, the evidence of which may 
be traced in the nerve itself and in its 
sheath, conveyed from diseased portions 
of the brain into the subvaginal spaces by 
a powerful lymph-current. The patho- 
genic material will accumulate mostly at 
the cul-de-sac of the space next to the 
globe and therefore produce the most 
striking changes at the intra-ocular end. 

Purulent irido-choroiditis gives another 
example of the rapid transportation of 
purulent matter from the cranial cavity 
through the optic sheaths into the peri- 
choroidal space by means of the lymph- 
current. The mechanical congestion in 
choked disc is due to a compression of the 
vessels by inflammatory products in the 
substance of the papilla. The intra- 
cranial pressure, as well as the distension 
of the sheath, alone do not cause but 
may intensify the process. Direct pres- 
sure on the optic fibres in the chiasm, at 
the optic foramen or at the base of the 
brain, by tumors, internal hydro- 
cephalus, distended third ventricle, menin- 
geal exudations, aneurisms or exostoses of 

the cranial bones may cause simple atro- 
phy of the optic nerve without preceding 
papillitis. Blindness, however, may occur 
in diseases of the brain even without oph- 
thalmoscopic changes. 

This brings us to the second point of 
relation of the eye to the brain — namely, 
the anatomical. In order to get an exact 
idea of the range of the visual nervous 
system we have to trace it from its per- 
ipheral termination and follow it to its 
nuclei and centres in the cortex of the 
brain. It will be readily conceived that 
we cannot do this anatomically or histo- 
logically. It is only possible by a combi- 
nation of the conclusions obtained by ana- 
tomical, pathological, clinical, physiologi- 
cal and experimental researches. The 
peripheral termini of the visual organ — 
the cones and rods of the retina — which 
are excited by their adequate stimulus, the 
light, are connected with nerve fibres 
without medullary sheaths, being simple 
axis-cylinders spreading in the innermost 
layer of the retina. They all converge in 
the optic disc where they assume neurog- 
lia and form the trunk of the nerve. In 
the orbit this, about thirty millimetres 
long, runs to the optic foramen and meets 
its partner of the other side in the chiasm. 

In regard to the position of the fibres 
in the optic nerve supplying the different 
portions of the retina, a case published by 
Schmidt-Rimpler {Arch, of Ophth.^ xix., 
p. 133) gives us valuable information: A 
man received, from a blow with a spade, 
a comminuted fracture of the posterior 
portion of the right parietal bone, a few 
centimetres below the sagittal suture. 
Left-sided hemianopia of the right eye re- 
sulted. The post-mortem examination 
revealed constriction of the upper part of 
the right occipital lobe. The secondary 
degeneration showed the following distri- 
bution of the fibres in the optic nerve: 
*'In the vicinity of the eye, the fibres 
supplying the macula lie in a wedge-shaped 
bundle on the temporal side of the nerve; 
the fibres of the temporal portion on the 
upper and lower periphery, encroaching 
somewhat upon the temporal as well as the 
nasal side ; the fibres of the nasal portion 
in a part embracing the centre of the op- 
tic nerve and the middle third of the nasal 
half of the periphery. In the neighbor- 
hood of the optic foramen, the fibres which 
supply the temporal portion of the retina 
occupy the lower periphery of the nerve,a 



Vol. Ixix 

larger portion of the nasal and a small, 
lower one of the temporal periphery ; those 
supplying the nasal portion of the retina 
occupy especially the upper periphery; 
whilst the macular fibres are found more 
in the centre/' The assertion of Siemer- 
ling that the uncrossed fibres should lie 
on the lateral side of the nerve seems not 
proven; nevertheless individual differ- 
ences are possible. 

This way of tracing the visual fibres, 
granted in this case by nature, was antici- 
pated and experimentally cultivated by 
Von Gudden as a special method of inves- 
tigation — the degeneration method or so- 
called atrophy experiments — and it is due 
to this mode of research that we owe our 
chief knowledge of the arrangement of 
the optic fibres in the chiasm, and of their 
further course in the brain. His experi- 
ments on animals proved a semi-decus- 
sation of the fibres in the chiasm in the 
rabbit, cat and dog, and his studies of 
horizontal sections of the human chiasm 
resulted in his observation that the fibres 
which cross lie mostly in the lower half of 
the chiasm and those which do not cross 
in the upper half. 

Michel is perhaps the only author who 
insists on the total crossing in the chiasm 
in the higher mammals. But his observa- 
tions are conclusively refuted by the ex- 
periments of Singer and Munzer, and, 
very recently, of Darkschewitsch {v. 
Oraefe's Arch., 37, 1891). Bernheimer 
(Arch, of Ophth., xx. 1891), following 
the course of the optic fibres by means of 
the development of their medullary sheath 
in thin serial sections of the human chi- 
asm, proved that there are fibres in the 
upper half of the human chiasm which 
pass directly from one tract to the nerve 
of the same side, and that the number of 
the crossed fibres is considerably greater 
than the number of the direct ones. From 
these and other observations we are justi- 
fied in taking for granted that the fibres 
of the chiasm intricately interlace, and 
cross one another so that, of the optic nerve, 
about three-fifths — representing the fibres 
from the nasal side of the retina — pass 
into the opposite tract, and two-fifths — 
from the temporal half of the retina — en- 
ter into the tract of the same side. 

According to Siemerling, the uncrossed 
bundle lies in the centre of the tract and 
never reaches the periphery. Delbrueck 
{Arch. f. Psych, vol. xxi 1890) says : 

'^ In the tract the rule seems to be that 
the direct fibres are mingled with those 
that cross." Both tracts diverge back- 
wards and form a rhombus with the cere- 
bral peduncles, pass under these and over 
the gyrus hippocampi and divide into 
roots. The lateral root goes to the corpus 
geniculatum laterale ; to the thalamus 
opticus, especially its posterior portion the 
pulvinar, and to the anterior corpora 
quadrigemina. In the latter, commissures 
of opticaljfibres of both sides are observed, 
which Charcot took for the complemental 
decussation of the fibres not yet crossed ; 
but this theory is unproved. These 
ganglia are the primary optical centres 
from which the radiating visual fibres of 
G-ratiolet spread into the white substance 
and the grey cortex of the occiptial 

The occipital lobe is considered to be 
the centre of vision, although the exact 
delimitation of the visual sphere has been 
a matter of controversy in the investiga- 
tions of many physiologists. Besides, it 
is now generally agreed that each species 
varies somewhat in its functional areas, so 
that we cannot simply apply physiological 
results in animals in forming an exact 
localization of the human function, but they 
are of great help. Munk first showed that 
unilateral extirpation of the visual sphere, 
by a section in the parieto-occipital fissure, 
localized it exclusively in the occipital lobe 
and produced homonymous hemianopia 
from paralysis of the corresponding sides 
of both retinae. Ferrier (Croonian Lec- 
tures, 1890) supposes that Munk^s opera- 
tions for removal of the occipital lobe 
would be the cause of secondary implica- 
tion of the angular gyrus or its connec- 
tions. He thinks, from the results of 
bilateral destruction of the angular gyrus 
described by himself, Munk and Schaefer, 
" that the angular gyri are more par- 
ticularly related to the area of distinct 
vision and, accordingly with the maculas 
luteae. The pathological facts in man 
render it necessary to assume that the re- 
gion of the yellow spot is represented in 
the angular gyrus of each hemisphere, 
though more in that of the opposite side." 
"It is in the higher visual center, where 
the two half -vision centres are probably 
blended, so that the former can compensate 
its fellow of the other side to some extent, 
whereas the half vision centres cannot 
supplement each other." (Growers.) 

July 29, 1893. 



The partial defects in the visual field 
seem to be dependent on partial lesions of 
the optic radiation and not of the cortex. 
The hypothesis of Munk and Schsefer, 
that Ihe different portions of the retina 
are represented in corresponding regions 
of the occipital lobe, cannot be considered 
as a fact. Ewens has, under the direction 
of Ferrier, collected and analyzed the 
majority of the recorded cases, with necrop- 
sies, of hemianopia, depending on cere- 
bral lesions with implication of other re- 
gions. Of 41 cases of hemianopia, 15 
were from diseases of the occipito- angular 
region, 2 of the angular and supramarginal 
gyri only, 15 from disease of the occipital 
lobe alone. In the other cases the lesions • 
were of a diffused character, the angular 
gyrus being implicated in all. Seguin and 
Nothnagel think that the cuneus, and 
Wilbrand that the apex of the occipital 
lobe, have a special relation to visual per- 
ception. According to Ferrier the visual 
area of the cortex is not a merely 
functionally differentiated region capable 
of replacing or being replaced by other 
cortical areas, in as much as destruction of 
the visual centres leads to atrophy in the 
primary optic centres, optic tracts and 
nerves ; and conversely, destruction of the 
optic radiations leads to atrophy strictly 
confined to the regions included within 
the visual zone. 

The chief functional disturbance in le- 
sions of the visual path from the optic 
centres down to the chiasm, is homony- 
mous or lateral hemianopia of the oppo- 
site halves of the visual field, which may 
be complete or incomplete. The line of 
division is usually sharp and vertical, and 
the blind sides usually have no sensation of 
light. Central vision is often preserved 
corresponding to a slight projection of the 
line of separation for three to five degrees 
into the blind side at the region of the 
macula. But the defective half never en- 
croaches upon the seeing side beyond the 
point of fixation, so that this would be 
situated in the blind portion. The ex- 
planation of this was the assumption that 
the macula of each side receives fibres 
from each tractus. If this be the case, 
in lateral hemianopia from a disease 
of one occipital lobe, destruction of the 
other occipital lobe would produce abso- 
lute blindness through bilateral hemiano- 
pia. Foerster, however, observed such a 
case of bilateral hemianopia. (V. Qraefe's 

Arch., vol. 36, No. 1, p. 94), in which 
the area of central vision was preserved in 
both halves of the visual field. He thinks 
it therefore to be more reasonable to attri- 
bute the preservation of central vision to 
a specially favorable arrangement of blood 
vessels supplying the sphere of distinct 
vision in the occipital cortex. Even if by 
thrombosis of the main vessel supplying 
the occipital lobe, the nutrition of the 
cortex in a large extent is cut off, the zone 
of distinct vision, by the numerous anas- 
tomoses of its vessels, receives sufficient 
nutrient material to preserve its function. 
Schweigger {Arch, of Ophth.., 1891, 1, p. 
84) confirms Foerster^s hypothesis from 
the observation of a similar case of bilat- 
eral hemianopia with preservation of a 
limited central field of vision, which he 
supposes to be due to a particular arrange- 
ment in the central apparatus. Foerster 
infers from his case that the cortex of the 
occipital lobe is the centre for the sense of 
locality and the topographical ideation and 
representation, no matter whether acquired 
by the visual or tactile organs or the per- 
ception of muscular movements, or by de- 

If homonymous hemianopia shall be of 
localizing value concomitant symptoms 
are to be looked for. For distinguishing 
tract and central hemianopia Wilbrand 
has suggested the following test advocated 
by Wernicke and Seguin: If the pupil 
does not react to light thrown on the 
hemianopic portion of the retina the op- 
tic tract is affected, because the pupillary 
as well as the visual fibres lie in this path, 
being connected with the oculo-motor 
centres by the ganglion habenul8e,the pos- 
terior commissure and the nucleus of 
Von G-udden. The pupillary fibres have 
a thicker calibre than the visual fibres ac- 
cording to Key, Retzius and Von Gudden. 
Lesion of the cortical centres causes hemi- 
anopia with complete hemiplegia, and 
aphasia is likely to be caused by a soft- 
ening of the gyri at the fissure of Sylvius 
— namely, the inferior parietal lobule, the 
supramarginal and the angular gyrus. 
The destruction of the latter, especially 
in the left hemisphere, is generally asso- 
ciated with the special form of sensory 
aphasia, word-blindness or alexia. The 
patient sees the words, but cannot read 
them from a loss of his visual memory of 
symbols describing objects. In paraplexia 
he reads other words than those which he 



Vol. Ixix 

wants to read. Dyslexia, which oaght to be 
called dysanagnosia, was first described by 
Berlin, in 1883, as a disinclination to read, 
as if it were impossible to make the neces- 
sary mental effort. Snch a patient is unable 
to read to himself or aloud more than four 
or five words ; he then becomes exhausted. 
Vision may be perfect, and there may be 
no asthenopia from a refractional error. 
In six autopsies lesions were found in the 
left hemisphere, in Broca's region not 
far from the third frontal convolution. 

The other kind of hemianopia, heteron- 
ymous hemianopia, embraces those cases 

in which either both temporal or both 
nasal halves of the visual field are want- 
ing. Lesions of the central portion or 
of the anterior or posterior angle of the 
chiasm causes temporal hemianopia by af- 
fecting only the fibres that cross from 
the nasal half of each retina. Damage 
to both lateral angles of the chiasm causes 
nasal or medial hemianopia, by affecting 
only the non- decussating fibres. The lat- 
ter is extremely rare. Monocular hemi- 
anopia is the consequence of lesion of 
one nerve in front of the chiasm or at one 
lateral angle. 


p. 0. KEEF, Oconto, Wis. 

The surgeon of to-day cannot afford to 
treat the most trival injury carelessly. 

The study of bacteriology shows beyond 
doubt, that wound infection is due to the 
presence of pathogenic germs which can 
be excluded by proper antiseptic precau- 
tions. This knowledge is not confined to 
the profession, but people know enough 
about blood-poisoning to ask some very 
embarassing questions when certain symp- 
toms manifest themselves, and if a life or 
limb is lost the surgeon is liable to be de- 
fendant in a suit for malpractice. 

It is only by a thorough knowledge of 
the causes of infection and by the most 
scrupulous attention to detail that we can 
do good, clean surgery. The wound or 
field of operation and everything which 
may come in contact with it, must be thor- 
oughly sterilized. It is not sufficient to 
apply a pad of iodoform gauze or other 
antiseptic dressings over a wound, as they 
have no power to exert any influence over 
germs deeply seated — and they need not be 
yery deep either, as the antiseptic must 
come in actual contact with every germ 
and remain so for some time to destroy its 
vitality. I have had a good many incised 
and lacerated wounds come under my care 
after they had been dressed elsewhere 
quite expensively in the matter of anti- 
septics, but the first and most important 
point, aseptisizing the part, was neglected 
or imperfectly done, as underneath the 

*Read before the Wis. State Medical Society, May, 

dressings the wounds were freely suppur- 

No doubt those men thought they were 
doing antiseptic surgery, and will in time 
either have their eyes opened to the fact 
that some of the details were lacking, or 
they will join the rapidly decreasing army 
of unbelievers. 

The abdominal surgeon rarely infects 
the abdomen, much less should we have 
infection in our ordinary operations. 

The laudable pus of our older teachers 
is a disgrace to the surgeon of to-day, and 
the law requires better work of the coun- 
try doctor of the present time than it did 
of the city expert of twenty years ago. It 
seems to me that it ought to be almost 
impossible for the recent graduate to do 
unclean surgery, as he is taught so thor- 
oughly by precept and example that he 
could not think of making or touching a 
wound without proper preparation. It is 
different, however, with the older men in 
the profession. Many of us were plant- 
ing microbes before antiseptics were ever 
thought of. 

We have to learn the new way and also 
to break ourselves of old habits, not an 
easy thing to do. I have been doing 
what I called antiseptic surgery for about 
twenty years, but until within about the 
last five years it was very unsatisfactory. 
The following report of cases shows the 
value of thorough asepsis and antisepsis, 
and tnat we may now expect to succeed in 
the most desperate cases. 

July 29, 1893. 



Case I. May 25th, 1891. Arthur B. ; 
came to me on account of sore leg. He 
was terribly emaciated, had frequent chills; 
temperature 103°; pulse 130. I found tar- 
sus and tibia entirely broken down, knee 
joint filled with pus, and on amputation be- 
tween middle and lower end of the thigh, 
found pus in the medullary cavity. I 
curetted thoroughly with a sharp spoon 
and irrigated with 1-1000 sublimate so- 
lution, and after introducing a few strands 
of coarse catgut the whole length of the 
canal, I closed the wound with sutures 
leaving the ends of catgut protruding. 
An antiseptic dressing was applied, not 
to be removed until indicated by abnormal 
mal temperature. May 26th, temperature 
101°; pulse 130. May 27th, temperature 
98-^°; pulse 100; eating and sleeping well. 
Temperature remained normal after this 
and patient improved rapidly, and on the 
fourteenth day the dressings were removed 
and the stump found to be entirely 
healed. The ends of catgut came off 
with the dressing, leaving a small granu- 
lating spot which healed in a few days. 
Patient went home three weeks after the 
amputation perfectly well. 

Case II. Adam H., age 29 years, a 
Bohemian laborer, called me on June 6th, 
1891, on account of an attack of appendici- 
tis. I advised an immediate operation as 
this was the second attack within four 
months. He would not consent and I did 
not see him again until June 13th. He was 
then in very bad condition. Profuse per- 
spiration ; temperature 104°; pulse 140; 
severe pain in the lower part of abdomen, 
which was bulging and dull. His bowels 
had not moved for six days, enemas fail- 
ing to bring away anything, and there 
was a constant prof use discharge of color- 
less glairy mucous from the anus. On 
the night of June 13th, he came to my 
hospital for an operation. The next 
morning his condition seemed much worse. 
There was uniform distension of the ab- 
domen and patient seemed in a state of 
' collapse. I operated immediately by an 
incision over the appendix, allowing the 
escape of gas, pus and feces. The incision 
was carefully enlarged upwards, the abdo- 
men and pus cavity thoroughly irrigated, 
first with hot sterilized water then with a 
1-3000 sublimate solution, followed again 
by irrigation with a large quantity of hot 
sterilized water. On examination I now 
found that the appendix had sloughed off 

and from this perforation the caecum was 
torn allowing pus and feces to enter the 
peritoneal cavity. I sutured the edges of 
the torn intestine to the parietal wound 
and introduced a large and a small drain- 
age tube to the bottom of the abscess 
cavity. The patient was now placed in 
bed and surrounded with bottles of hot 
water. Keaction was very slow. The 
cavity was irrigated with hot Thiersh's 
solution every six hours and it was not 
until the fourth day that any sign of im- 
provement took place. He then com- 
menced to gain and on June 29th, the ab- 
scess cavity was obliterated and I at- 
tempted to close the fecal fistula by paring 
the edges and suturing. The attempt 
failed as did several other attempts that I 
made. During the next three months I 
tried all the schemes I could think of, but 
each time after a few hours he would have 
severe pain and the fistula would burst 
open. I now proposed to unite the ilium 
with the colon to which he readily con- 
sented, and on October 12th, I made a 
median incision below the umbilicus and 
made an anastomoses of the lower end of 
the ilium and the descending colon by 
means of Senn's decalcified bone plates. 
The bowels moved naturally the next 
morning for the first time since his sick- 
ness began, and the fistula healed without 
any treatment except his wearing a pad of 
borated cotton pressed against it. I did 
not look for the site or cause of obstruc- 
tion of the colon because just after mak- 
ing the abdominal incision as I was lifting 
out the intestine the patient became 
asphyxiated and I had to complete the 
operation as soon as possible. On account 
of the ilium opening so low in the colon 
I expected that the feces would be fluid, 
but I have asked the man about it a 
number of times since, and he says he is 
all right and as well as ever. 

Case III. On June 27th, 1891, 
Thomas H., age six years, while playing 
in the barn fell with his knee on a scythe 
splitting the patella longitudinally from 
the center slanting outwards, so that it 
cut off about one-fourth inch of the 
articular surface and opened the capsule 
of the joint to the extent of one and one- 
half inches. The joint was filled with 
blood and hay seed and in order to 
properly irrigate I removed the smaller 
piece of patella and cleaned the joint 
thoroughly. The capsule and deep tissues 



Vol. Ixix 

were sutured closely with fine catgut and 
the skin ^ith silk sutures. A plaster of 
Paris cast was applied over the antiseptic 
dressing and left on for eight days. 
When removed the wound was entirely 
healed and passive motion made, which 
was slightly painful at first, but in a few 
days he began to walk with as good a joint 
as before. 

Case IV. On September 27th, 1892, 
Mrs. CO., age 28 years, was sent to me 
by Dr. Brett, of Green Bay. She began 
to have severe pain in the left side, in 
February, accompanied with chills and 
fever. When I first saw her she had lost 
seventy-five pounds in weight in seven 
months. She was still suffering severe 
pain and had slight chills. Her tempera- 
ture was 101°, and remained so until I 
operated on September 29th. Dr. Phillips, 
of Menominee, who was present saw her 
at the Providence Hospital in Menominee 
about three months before, and said he 
could by pressure reduce the size of the 
tumor, by forcing the pus through the 
tubes into the uterus. An incision was 
made along the linea alba and the tumor 
found firmly adherent. It was carefully 
enucleated. During the operation a few 
drops of pus appeared to ooze from the 
tumor where a firm adhesion had been 
broken up, and I packed the abdomen 
with sterilized gauze in case of possible 
rupture. The remaining adhesions were 
broken up and the tumor successfully re- 
moved. The pedicle and all bleeding 
points were ligated and cauterized^ and a 
large rubber drainage tube with a wick of 
iodoform gauze placed in Douglass' pouch 
and the abdominal wound closed. Two 
hours after the operation I gave -^ gr. 
morphia which was the only dose required. 
Temperature in the evening was 100^°. 
Next day, September 30th, temperature 
100°. October 1st, temperature 98^°. I 
removed drainage tube. The temperature 
remained normal after that and abdominal 
wound healed by first intention, except 
site of drainage tube which healed in a 
short time by granulation. 

During her four weeks stay at the 
hospital, patient had gained twenty-two 
pounds in weight and has been well since. 
The tumor was between four and five 
inches in diametre, consisting of one large 
thin-walled cyst filled with intensely foul 
smelling pus, and a few small cysts filled 
with a transparent gelatinous fluid. The 

fimbriated extremity was firmly adherent 
to the tumor, but the tube itself was 
somewhat thickened but contained no 
pus. I do not report this case on ac- 
count of its peculiarities but because one 
of the physicians present, quite a promi- 
nent surgeon, is reported to have said 
afterwards that the operation was un- 
called for and that the patient could have 
been cured by other means. Now, if an 
operation is not called for in such cases as 
this — when should we operate ? 

Case V. Nov. 16, 1892, I was called 
to Grillett to see E. K. , who on the eve- 
ning previous received four bullet wounds 
from a 38 caliber revolver, in various parts 
of the body. One of them entered the 
abdominal cavity by passing through the 
left ileum about its center. It passed up- 
wards and forwards and lodged in the left 
rectus. On cutting down on the bullet 
a few bubbles of gas escaped so the 
incision into the abdomen was com- 
pleted and the intestines examined. 

At one point in the small intestine there 
was some discoloration of the mesentery, 
and one side of the intestine had lost its 
glistening appearance. The descending 
colon was perforated and cut nearly half 
off, except a narrow bridge about \ inch 
wide between the two bullet holes. The 
mucus membrane was everted so that it 
completely filled both openings, prevent- 
ing almost absolutely the escape of fecal 
matter, and I failed to force any out by 
pressure on the bowel until I cut the 
narrow bridge ; thus nature had quite 
effectively protected the peritoneum and 
there was no hemorrhage to speak of. 
The wounded colon was repaired with a 
large number of Ozerny — Lembert sutures. 
The peritoneal cavity was thoroughly 
irrigated and the abdominal wound closed. 
I left him 1^ hours after the operation 
feeling well and he continued so until 
about noon on Nov. 18th, sixty-fours after 
the shooting; he became restless; his tem- 
perature, which had been 99° to 99|° fell 
to 96|-°, the abdomen began to swell and 
became tympanitic. I saw him about 
3 P. M. and he was in a state of collapse. 
I supposed the sutures had given away. 
He died about 10 P. M. just seventy- 
two hours after the shooting. Autopsy 
was made eighteen hours after death by 
Dr. Hinch, of Gillett, who kindly sent me 
sections of bowel. The sutured colon 
was perfectly united, but in the small in- 

July 29, 1893. 



testine were found three small perforations 
about I inch in diameter — two on one side 
of the bowel about ^ inch apart, and one 
on the other side directly opposite to them. 
I made a post mortem diagnosis of em- 
bolism of a mesenteric artery and necrosis of 
the corresponding part of intestine, proba- 
bly the part found discolored at the time of 
operation. I think in all cases where the 
mesentery is injured, the only safe plan is 
to remove a V shaped portion of the in- 

testine and unite by anastomosis or other 
means. It may be that many of the deaths 
after gun-shot wound are due to slight 
injury to the intestine or mesentery which 
is either not seen or thought not to be of 
any consequence, instead of failure of the 
part operated upon to unite. 

If a post-mortem had not been made 
in this case I would still think as I did 
when I saw him the last time alive, that the 
sutures had given away. 


C. C. MOORE, M. D., Philadelphia. 

In March, 1892, F. L., set. 73 years, 
came to my office for a troublesome 
winter cough so severe he could not rest 
at night. He had not laid down for some 
months, but slept in the upright position. 
This cough had been increasing for 
several winters and was apparently a 
case of chronic winter bronchitis of old 
age. He had not consulted any other 
physician though the coughing had been 
severe for some time. Objectively he was 
a large, strong man ; respiratory sounds 
negative, pharynx red, congested from 
constant coughing, but I could detect no 
cause for it. Nares clear and mucous 
healthy. I clearly had a case of reflex 
cough. I looked in the left ear and it 
was normal in every way. He protested 
his hearing was perfect. I put the ear 
speculum aside, then thought I would 
complete the examination and look in the 
right ear, where a large piece cerumen 
that filled the canal was discovered. I 
removed it with the syringe and warm 
water. This revived his memory and he 
told me thatjthirty years ago, while driving 
along a woods, some insect flew in his ear. 
It annoyed him for about an hour, then 
suddenly quit; he gave this no more at- 
tention, but always thought his hearing 
was somewhat impaired on that side. Re- 
moving this substance cured.his cough com- 
pletely, for more than a year has lapsed 
since. In the centre of the cerumen was 
a grain of sand the size of a bird shot. 
This had formed the nucleus for cerumen. 
It had probably been thrown from the 
carriage wheel, and caused the sensation 
like the buzzing of an insect. 

I consider the case exceptional, and it 
proves how misleading a symptom may be 
and that we can not always treat the 
symptoms. A cough, like a headache or 
neuralgia or pain, may be caused by dis- 
ease remote from the locality of the an- 
noying symptom. 

The Justifiable Prevention of Conception. 

The physician not infrequently has to 
warn against conception in cases where a 
pregnancy would endanger the life or the 
health of the patient. Pelvic contraction, 
abdominal and uterine tumors, etc., form 
such an indication. The advice to abstain 
from coitus is but seldom followed, and 
the means usually employed to prevent 
gestation (mechanical) are objectionable 
from a hygienic and ethical point of view. 
Kleinwachter has endeavored to find a 
remedy which would have none of the 
aforementioned drawbacks. fHe prescribes 
a cacao-butter suppository containing 10 
per cent, of boracic acid, to be introduced 
high up into the vagina. These supposi- 
tories dissolve in about one hour, and the 
liberated acid destroys the spermatozoa. 
Bichloride of mercury in 0.001-gramme 
doses can also be used, but in that case a 
vaginal douche has to follow the sexual 
act. The solvency of the suppository is 
heightened by adding one grain of oleum 
olivae. The author considers this a safe 
and sure remedy to prevent conception. 
Therapeutic effects may be combined by 
the adding of various drugs — for^instance, 
tannin in cases of uterine catarrh.— J/e^- 
ical Age. 


Society Reports, 

Vol. Ixix 


Stated Meeting, May 8th, 189S. 

The Peesidekt, Dr. A. M. Cart- 
ledge, in the Chair. 


Dr. W. 0. Egberts: This specimen is 
a fatty tumor which in itself does not 
amount to much, but the location from 
which it was taken makes it rather inter- 
esting. The patient was fifty- five years 
of age, and the tumor was first noticed 
three years ago; it was then quite small 
and was thought to be an enlarged gland 
in the carotid triangle of the neck. It 
has grown gradually. At the time of its 
removal, ten days ag:o, it had attained a 
considerable size and produced a good 
deal of discomfort from pressure upon 
the structures of the neck. It is the first 
time I have ever seen a fatty tumor in 
this locality, and for that reason I report 
the case. Hemorrhage, which would have 
been considerable, was controlled with 
clamp forceps. I was assisted in the 
operation by Drs. Joe Anderson, Beard 
and Block. 


Dr. E. E. Palmer: Did the tumor 
have any effect on the breathing? 

Dr. W. 0. Egberts: It had begun to 
do so. 

The essay of the evening was then read 
by Dr. E. E. Palmer. 


Contrary to a quite common belief and 
mode of procedure, the scientific treatment 
of syphilis is anything but simple or stere- 
otyped. Attention to what at first seem 
but little things constitute a very impor- 
tant part of the surgeon^s duty. He has 
a great deal more to do than to simply 
order two years or more of constitutional 
treatment with a cessation from tobacco 
and alcohol. Among the other duties 
that devolve upon him, are frequent in- 
spection of the nose, mouth and pharynx. 
The mere casual search for mucous 
patches in the latter two will not sufl&ce. 
On taking charge of the case, he should 
familiarize himself fully with the pre- 

syphilitic topography of these parts. In 
so doing it will be a matter of surprise- 
how frequently their condition is found 
to be a vicious one. Notably is this the 
case as regards the mouth. Scurvy, 
snags, or a general foul and so insanitary 
condition being frequently present, calling 
for correction. When possible, each 
patient, unless the mouth be found in an 
excellent state, should be sent at once to a 
competent dentist to have ^ his teeth 
cleansed, filled, etc. , and he should be or- 
dered not only a good dentifrice with a. 
soft brush and pure castile soap for daily 
use, but from time to time when any spe- 
cific evidences appear, a mouth wash of 
listerine, zymocide or the like used, if pos- 
sible, in full strength. 

Enlarged or chronically diseased tonsils 
should be removed, and chronic non-spe- 
cific catarrhal conditions of the pharynx 
being common, these parts must be 
brought into the best possible conditions 
by local and constitutional treatment. 
But of vastly more importance is the care 
of the nares. It is reprehensible in the 
extreme to wait until bloody discharges or 
bits of exfoliating turbinated bone tell the 
story of probably irreparable damage. 

It must not be overlooked that while 
destructive, and so incurable, phases of 
syphilis usually attack the nares late in 
syphilis, they are' also usually pre- 
ceded by early and curable troubles that 
lay the foundation, when overlooked, for 
the final damage. 

One object I had in calling your atten- 
tion to this matter to-night is to urge in 
such cases, both as an exploratory and as 
a curative measure, the use, with a post- 
nasal syringe, of a combination in equal 
parts of Dobell's solution and 15 vol. 
peroxide of hydrogen. When trouble 
exists, the discharge of, sometimes, enor- 
mous quantities of decomposed mu co-pus 
follows with a great sense of relief and 
comfort on the part of the patient. Pain 
is rarely experienced, and where it is, a one 
per cent, solution of cocaine snuffed from 
the hollow of the hand suffices for its relief. 

July 29, 1893: 

Society Reports. 


While I do not urge this as a one remedy 
in nasal syphilis, I desire to add it as an 
important combination to the list already 
recorded. Gnmmata of the hard palate 
are usually of a tertiary character. I have 
recently relieved two such cases without 
perforation by heroic mercurialization and 
the application of saturated solution of 
silver nitrate daily — better results than 
are obtained usually by the mixed or pure 
iodide treatment. 

A case recently under my care illus- 
trates the necessity of close observation in 
upper air passage complications. An 
actress,leading lady of a prominent combi- 
nation, came to see me with acute aphonia. 
She was greatly distressed, as she stated a 
surgeon of Johns Hopkins Hospital had 
told her her disease was syphilitic in 
character. She was vehement in her 
assertions that she had never had syphilis. 
On examination of her mouth I discovered 
an enlargement, median of the hard palate, 
gumma as large as an ordinary grape. I 
sent her to see Dr. Cheatham, who found 
no evidence of syphilis in her throat and 
soon relieved her. I saw her daily for 
about two weeks as also did Dr. Cheatham, 
and it was not long before we diagnosed 
the elevation to be a congenital deformity. 
The patient has since remained wholly well. 

The other doctor diagnosed syphilis, 
probably, from the supposed gumma, not 
having made, as I learned, a laryngoscopic 


Dr. W. 0. Egberts: In regard to 
peroxide of hydrogen in the nasal douche, 
I tried this on two cases and it produced 
such discomfort that I had to stop it. 
However, in these cases I used Marchand's 
peroxide of hydrogen. I have since used 
the Oakland Company's, which did not 
produce any of these disagreeable effects. 
I would like to ask Dr. Palmer if he does 
not think the douche would answer the 
same purpose as the post nasal syringe ? I 
rely chiefly in the management of these 
cases upon constitutional treatment. 

Dr. E. R. Palmer : The thing is to get 
them to use it. In cases of early syphilis, 
I have removed from the nostrils some- 
times a double handful of muco-puru- 
lent material by throwing the syringe 
twice full up over the velum palati. I 
have never seen any inflammatory trouble 
follow use of the syringe. I use the O.C. 
peroxide solely. 

Dr. Wm. Cheatham : I remember the 
case Dr. Palmer refers to very well. I did 
not believe it was a node or gumma. I 
saw an article a short time afterward where 
a gentleman reported a lot of these con- 
genital projections. 

I think Dr. Palmer's solution of perox- 
ide a little strong ; it is liable to be forced 
into the middle ear and up into the sinuses. 
I think he will flnd that a 2 or 3 volume, 
will do just as much good and is much 
safer. Another precaution I would like 
to call Dr. Palmer's attention to, is that 
of blowing ; if you have the patient blow, 
some of the secretion or solution is very 
liable to get into the middle ear. Always 
after using spray, douche or post nasal 
syringe, let them draw it down instead of 
blow, thus avoiding danger to the ear. 

Dr. Roberts asked about the douche. 
No anterior treatment reaches more than 
two -thirds of the nose. Where a solution 
is used anteriorly, either with spray or 
douche, it does not reach over the turbi- 
nates, but if you use it posteriorly it does. 
Men write a great deal about syphilis of 
the upper air passages, I do not think I 
I have but one case now ; syphilis shows 
about one-third the way back in the right 
nose in this case, which I have relieved by 
chromic acid. I think it was gumma ; had 
primary lesion four or five years ago. In 
late syphilis I find cod liver oil very bene- 

Dr. a. M. Cartledge: I suppose my 
experience is like that of most other phy- 
sicians; I find some cases recover very 
promptly under treatment while others are 
very obstinate. I formerly used nitrate 
of silver nearly altogether. In the last 
year or so I have been using gargles or 
mouth washes of mercury bichloride, using 
it as part of the treatment. I think 
bichloride wash,just as a sanitary measure, 
is a good thing. Many of these cases 
demand other things than iodide of potas- 
sium ; as a rule I think we neglect the 
general building up of these people too 
much. I believe, in the late manifestations 
of syphilis, quinine, cinchona, cod liver oil, 
etc., may be given with excellent results. 

Dr. E. R. Palmer: I am surprised that 
Taylor, in his work in Hare's System, objects 
to the use of the black wash in syphilitic 
troubles. He says that in private practice it 
nauseates his patients, but in the Vander- 
bilt Clinic he gets very fine results from it. 
I think a great deal of the black wash 


Society Reports. 

Vol. Ixix 

and advise its use in suitable cases. It 
was more to call attention to the matter of 
mouth hygiene than anything else that I 
prepared the short paper read this 

In the matter of cod liver oil — as most of 
you know, I taught lung diseases for sixteen 
years, and I believe that benefit may be 
derived from the administration of cod 
liver oil vastly more in late syphilis than in 
phthisis. I prescribe it nearly every day ; 
there are three or four favorite preparations 
among the emulsions and I give them, feel- 
ing absolutely certain that beneficial results 
will follow. My faith has very materially 
weakened in regard to the iodides ; I do 
not get results from them such as I would 
like or would expect, considering the re- 
putation they have had. 

I want to mention two other cases in 
addition to those referred to in the paper, 
where I have recently relieved gummata 
of the hard palate by the administra- 
tion of three to five grains of proto-iodide 
daily and daily application of nitrate of 
silver; both cases were completely cured 
without any destruction of the bone. 
One of the patients was a terrible acne 
subject; had been to Hot Springs twice; 
he could not take iodide of potassium with- 
out its producing very distressing condi- 
tions, tumefaction, tormina and all the 
other disagreeable symptoms. I gave him 
cod liver oil and he was then able to take 
the treatment without any trouble. 

The next case was double infection. 
While he was being treated for tertiary 
syphilis, contracted in 1885, he got afresh 
case. While under treatment for this new 
syphilis, he developed a gumma of the hard 
palate. He was given four or five grains 
of proto-iodide daily and, with the applica- 
tion of silver nitrate, got entirely well. 
I do not give iodide of potassium in con- 
junction with cod liver oil. I think iodide 
should be used singly, but my results in 
its use are not very encouraging except in 
brain and bone syphilis. In such cases 
iodide is indicated sometimes to the Hot 
Springs extreme, 120 grains three times a 
day or even more will be found very bene- 

Dr. Wm. Cheatham: I would like to 
call attention to the fact that in some 
severe cases of secondary syphilis of the 
tonsils, pharynx and inside of cheeks, 
constitutional treatment appears to have 
but little efiect, until the above lesions 

are relieved by local treatment. I use in 
such cases the ' ' black wash " or hydrogen 
peroxide (Oakland Co. ) 10 vol. ,six ounces ; 
glycerine two ounces ; hydrarg. bichloride 
one grain locally. I do not know how to 
explain this, but I know it to be a fact. 

De. H. H. Grant: I would like to ask 
Dr. Palmer if he uses mercury hypoder- 
matically in the treatment of syphilis. 

Dr. E. E. Palmer: I have never em- 
ployed mercury hypodermatically. I think 
injections might be used simply for their 
local effect. For instance, some men in- 
ject gummata and nodes in the treatment 
of syphilis with view of getting the local 
effect of the agent. It has never become 
a part of the treatment in this country. 
It is exceedingly painful and has not done 
the work it was claimed it would do. I 
think this is the reason why the hypoder- 
matic use of mercury has not become more 
general. It was claimed that by this 
means in a three months' course of injec- 
tion, syphilis could be eradicated from the 
system. I do not believe this will ever be 
the case; you must treat your patient 
over a considerable period of time, no 
matter what agent you use or the manner 
of introduction. 

Dr. H. H. GtRAI^t: Do you not think 
that the good effect derived from the 
administration of cod liver oil is owing to 
its constructive powers, aiding the consti- 
tuticn to avert or overcome the tertiary 
manifestations, thus rendering iodide un- 
necessary ? 

Dr. E. R. Palmer: I do not see how 
we can well explain the wonderful results 
obtained by the use of cod liver oil. I 
hardly think it can be explained by the 
small amount of iodine it contains. 

Dr. a. M. Oartledge: Do you not 
think that mercury when applied to the 
local manifestation of syphilis, has a local 
specific effect ? 

Dr. E. R. Palmer : Unquestionably it 
has. The action of mercury is as a solvent 
of the neoplasm, and this is where I would 
favor injection, in pronounced lesions, 
of the gummata to get the local effect 
of the mercury. The point I wished 
particularly to emphasize, is the care of the 
mouth; that it is not sufficient to look into 
the mouth for mucous patches, etc. You 
would be surprised at the number of peo- 
ple that present themselves with the most 
horrible mouths. Scurvy is a very common 
condition; teeth loose, breath foul, gums 

July 29, 1893. 

Society Reports, 


bleeding and all those other conditions that 
make the mouth look more like a cess-pool 
than the sweet, clean organ that it should 
be. Another point I want to emphasize 
is that the physician should familiarize 
himself with the presyphilitic topography 
of the case. 

In the case of the actress with the 
growth in her mouth; if the mouth had 
been carefully eiamined previously she 
would have been familiar with the true 
nature of the trouble there. She was not 
even able to tell how long this growth had 
been present. 

In this connection I would like to men- 
tion that I saw to-day a lady who had the 
change of life ten years ago, a wonderful- 
ly well-preserved woman, with the two 
tonsils as large as you will see in very much 
younger subjects; two immense tonsils 
almost meeting in the pharynx. I was 
laboring under the impression that the 
tonsil atrophied in old patients. 

Dr. Wm. Cheatham: Such conditions 
are not common. 


Dr. a. M.Vance : I would like to make 
a continued report: At the last meeting of 
this society I presented a specimen con- 
sisting of a portion of thyroid gland 
removed a few days previously. At that 
time I read a letter from Dr. Louis Frank, 
written me after he had made a careful 
microscopical examination of the growth, 
in which he pronounced it thyroid gland. 
You will remember at that time there was 
some doubt expressed by one or two mem- 
bers as to the nature of the tumor, that is 
whether it was really thyroid tissue. I 
have since had it examined by several other 
microscopists and they all agree with the 
report made by Dr. Frank. I will read 
their several letters, also a short report from 
the JSIew York Medical Journal, and a 
quotation from the American Text Book 
of Surgery, bearing on the question. 


"At a meeting of the Paris Medical 
Society of the Hospitals, held on March 
17th, reported in the Union Medicale for 
March 21st, Dr. Chantemesse and Dr. 
Marie described some little glandular 
organs found in the neighberhood of the 
thyroid gland in man, and confirmed 
Sanderstrom's description of parathyreoid 
glands. They form two groups, one of 

which, the more important, is situated at 
the level of the point of penetration of 
the inferior thyroid artery. This group 
consists of two or three glandules, none 
of them larger than a lentil, round, ovoid, 
or kidney shaped. The other group, 
generally less voluminous, is at the level 
of the point of penetration of the superior 
thyroid artery. These little glands are 
free or surrounded with connective tissue 
and provided with a minute vascular 
pedicle. Their structure is very difterent 
from that of lymphatic ganglia. They 
are divided into lobules by a connective 
tissue stroma, and are traversed by 
numerous capillary vessels. The lobules 
are formed of little cells sometimes dis- 
posed irregularly, sometimes arranged in 
a circle, the periphery of which is 
bordered with little cubical cells, and 
the centre filled with irregularly dis- 
posed elements. Occasionally, true tubes 
of epithelial cells may be made out, 
and at the periphery of the glands there 
are often to be seen little rounded masses, 
the central part of which contains a 
material having a colloid appearance. 
Stress was laid on the fact that these 
glandules were situated externally to the 
capsule of the thyroid gland, and it was 
urged that they be left in cases of thy- 
roidectomy, for they were capable of a 
compensatory function analogous to that 
of the pituitary gland." — {N. Y. Medical 
Journal, April 15th, 1893.) 

"The body is quite likely to be ac- 
companied by accessory masses of similar 
tissue, which may be connected with it or 
may lie behind the trachea, or beneath 
the base of the tongue, or elsewhere about 
the middle or anterior portions." — [The 
American Text Book of Surgery.) 

" Dr. a. M. Vance: I agree with Dr. 
Frank^s statement, having made a micro- 
scopic examination of tissue and would 
like to add that I believe it to be not only 
thyroid gland tissue but a goitre." 

Dr. Wm. Vissman." 

'^My Dear Doctor Vance: "I was 
requested by Dr. Kodman to examine a 
piece of tissue unaccompanied by clinical 
history, etc. 1 did so and after examin- 
ing ten or twelve sections reported it as 
thyroid tissue. I presume this is the 
same tissue examined by Drs. Frank and 
Vissman and if so, I concur in. their 
diagnosis." Eespt. 

H. M. Goodman, M. D." 


Society Reports. 

Vol. Ixix 

'' My Deak Doctor Vance : ^' At the 
request of Dr. Goodman, I examined a 
section of the tissues above described, and 
found it to present all the characteristics 
of thyroid tissue." 

Yours very truly, 

H. A. OOTTELL, M. D." 

"Dear Doctor Vance : "Macroscopi- 
cally and microscopically I think the 
tissue sent me by you to be a thyroid 

Jno. L. Howard, M. D." 

"Dear Doctor: Just coming home 
I found your note requesting me to give 
you my statement in regard to the speci- 
men examined for Dr. Kodman and I 
gladly do so, as I have done at the time to 
him. The piece of tissue handed to me 
by Dr. Rodman was partly dried at the 
oater surface and consisted of two sorts of 
tissue to the naked eye, one grayish and 
glistening, the other a small nodule at the 
periphery, a yellowish white firmer tissue. 

Microscopic examination shows the 
tissue to be made up of gland-acini, vary- 
ing in size from 2V to sou inch, irregular in 
outline, separated from one another by a 
delicate fibrous wall, and lined with 
roundish nucleated cells somewhat larger 
than the ordinary lymph corpuscles. In 
some of the larger acini, the lining cells 
are flattened by compression of a clear 
homogenous refractive substance filling 
the acini (colloid material), some few of 
the acini are filled with an organized tissue 
made up of a delicate connective tissue, 
some others have a yellowish brown pig- 
ment lying within the colloid material. 

The mentioned yellowish white portion 
is made up of densely packed alveoli which 
are filled partly with colloid material but 
the majority with densely crowded cells 
of the same type as those lining the wall. 
The stroma is supplied with a moderate 
amount of small blood vessels. 

As to "the resume " — I have not the 
least hesitation or the slightest doubt to 
state, as I have done to my friend Dr. 
Bodman, that the specimen in question is 
a piece of thyroid gland in a state of (very 
common in this structure) colloid de- 
generation, or as you find it named by 
German pathologists Struma OoUoides. 

Hoping to have served you by this 
report " 

I am sincerely your friend, 

C. Weidner." 

Dr. Frank has made several sections of 
the growth, which I have had him bring 
here this evening and would be glad to 
have you examine them through the 
microscope, also compare them with other 
specimens of thyroid tissue. 

Dr. W. L. Rodman: I wish to add a 
word in regard to Dr. Weidner's opinion: 
Dr. Vance was kind enough to give me a 
portion of the specimen ; I had it in my 
buggy and in driving down town met Dr. 
Weidner, who said he would be very glad 
to examine it. He made an examination 
and made the same report to me verbally 
that he has in writing to Dr. Vance. I 
take pleasure in stating that Dr. Weidner 
further said he was not certain, but the 
point in the section he made there seemed 
to be cells of a sarcomatous nature. I do 
not mean to quote the doctor as saying 
that it was necessarily sarcomatous de- 
generation of the thyroid, but he found 
cells looking very much like sarcoma cells. 
I stated at the last meeting that if this 
was thyroid tissue, I was satisfied that it 
was an accessory thyroid that occurs 
occasionally at different points in the 
neck, sometimes inside the larynx and 
trachea, and when they do occur, they 
are subject to the same enlargements as 
the thyroid-cystic degeneration and fibrous 

From the unanimity of the report made 
by the microscopists, I am satisfied that 
this must be thyroid tissue. I am still 
under the impression, however, that it is 
an enlarged accessory thyroid, as the 
isthmus is very infrequently the seat of 
goitre, it nearly always affecting one of the 
two lobes, preferably the right. Hyper- 
trophy of the isthmus is very infrequent. 
In a paper that I am now preparing, which 
will be read at the next meeting of the 
Kentucky State Medical Society next 
Thursday morning, I take up diseases of 
the thyroid as well as other tumors of the 
neck. I have gone over the literature very 
carefully, and am, therefore, in position 
to speak advisedly upon the subject. 
Benign solid growths practically do not 
affect the thyroid gland, the only one 
being the fibrous bronchocele or hyper- 
trophy of the gland. Cystic degeneration 
is frequent. As to malignant growths: 
Kaufman, in an elaborate paper on the 
subject, was able to collect only 21 cases 
of carcinoma affecting the thyroid, and 7 
cases of sarcoma. So I think I was right 

July 29, 1893. 

Society Reports, 


in stating that benign growths of the 
thyroid are practically unknown, and that 
malignant growths are verv rarely found, 
so rarely that I doubt if any member 
present has ever seen one. 

Dr. Louis Frank (Visiting): I was 
iisked by Dr. Vance to bring some sections 
(of the specimen handed me by him) here 
to-night to demonstrate the correctness of 
my diagnosis. His report from the other 
microscopists of the city was entirely un- 
solicited by me. I intend to stand on the 
report I have already made. Some one 
has mentioned the short time consumed by 
me in making an examination of this 
tumor. I will state that, as the specimen 
was fresh, no time was required further 
than to make a few sections of the growth 
and mount them for examination, proba- 
bly ten or fiften minutes. 

Possibly I misunderstood Dr. Eodman 
in saying that non-malignant growths of 
the thyroid were very infrequent ; from my 
reading (and I have looked over two or 
three books on pathology since this tumor 
was sent to me), I find that cystic growths 
of the thyroid, what we ordinarily term 
struma, are quite common. I agree with 
Dr. Rodman that malignant growths of 
the thyroid are very rare, comparatively 
few cases being on record. Benign 
growths, though, are very frequent, 
being either of the cystic variety or being 
fibroid in character; the latter variety 
being usually a result of changes follow- 
ing hemorrhage of the cystic tumors. 

Dr. H. M. Goodman (Visiting) : I have 
very little to add to the foregoing remarks, 
except to define my position in connection 
with the examination of the specimen. I 
worked under very adverse circumstances. 
I knew nothing about the case; a piece 
of tissue being handed me by one of 
my colleagues at the University with 
the request that I examine and report 
upon it. I remarked at the time that it 
was a very difficult thing to do in the 
absence of any clinical history, but as the 
tissue seemed to be tolerably hard and 
firm I immediately embedded it in 
colloidin, and made a few sections and 
proceeded to examine it. The first section 
showed thyroid tissue with increasing 
amount of colloid material in the sacs of 
the tissue. I am glad, for once, the micro- 
oscopists of the city seem to be agreed, 
and certainly I think the diagnosis is 
absolutely settled. I will add, however, 

that in sending the report to Dr. Rodman, 
I made the diagnosis of colloid struma. 

Dr. Louis Frank : I would also like to 
say that it is only by microscopical 
examination that we are able to recognize 
certain tissue macroscopically. It is the 
microscope that renders us able to know 
certain tissues, and that has by analyzing 
structures enabled us to say what they are 
when we next see them. Were it not for 
the microscope we would never be able to 
recognize carcinoma or any other growths 

Concerning the point made by Dr. 
Goodman in regard to the clinical history : 
The specimen was handed to me with no 
history whatever, except that the tumor 
was removed from the neck, consequently 
the question of clinical history did not 
figure in my diagnosis. You cannot 
always rely upon the clinical history for 


Dr. W. 0. Roberts: I will report a 
case I operated upon at the University 
Clinic last Tuesday morning. A man, 
thirty-five years of age, sixteen years ago 
had what was said to be pneumonia of the 
right side; had never been well since. Five 
years ago, a large swelling appeared Just 
above the edge of the cartilage on the 
right side and it was finally opened, dis- 
charging very profusely and has been dis- 
charging freely every since. Upon 
examination, I found the left side of the 
chest enlarged and the right side perfectly 
flat and dull clear up to the point of the 
scapula. I made an incision down to the 
seventh rib on a line with the posterior 
diameter of the aixillary space, found the 
ribs so close together that I could not 
get anything between them. I then 
resected a portion of the seventh rib, re- 
moving a piece probably about two inches 
in length. I then opened the chest and I 
think the foulest pus that I have ever 
smelled in my life came out. There must 
have been at least a pint of it, if not 
more. I inserted a large drainage tube 
without washing out the chest, emptying 
it as thoroughly as I could by changing 
the position of the patient, and sent him 
to the Sts. Mary and Elizabeth Hospital. 
He has gotten along without an untoward 
symptom and now the original opening is 
almost entirely closed. Nothing comes 
out of it. 


Society Reports. 


I report the case as being of interest 
because of the fact that this condition of 
empyema has lasted such a length of time. 
He dates it back sixteen years ; has never 
been able to breath well on that side since 
the attack of pneumonia. 


De. a. M. Vakce: I would like to 
ask Dr. Eoberts why he did not wash out 
the chest? 

De. W. 0. EoBEETS: Because of the 
fact that a number of sudden deaths have 
resulted from washing out the sac in cases 
of pyema, especially cases where the 
empyema was on the left side. 

De. a. M. Caetledge : I hope a con- 
tinued report will be made of this case, 
I do not think the man will get well. A 
lung compressed by an accumulation of 
pus for sixteen years will not get well as a 
rule with the resection of Ih to 2 inches 
of rib. The case is of such long standing, 
there is evidently a quantity of old fibrous 
tissue existing, and I do not believe there 
will be sufficient lung expansion to fill 
the cavity. I think there will be a dis- 
charging sinus requiring a more extensive 
operation. That has been my experience. 
The lung will not expand, and you will 
have to take out a section of two or three 
ribs, and break up adhesions that bind 
the lung down 

De. W. 0. KoBEETS: This is the sec- 
ond case I have had where this offensive 
pus existed ; both of them were operated 
upon at the University Clinic. The first 
case was several years ago. The man had 
been shot, the ball entering the upper 
part of the right side of the chest, between 
the third and fourth ribs, and had been 
discharging for something over a year; 
whenever he would lie down the pus 
would run out through the opening. I 
removed a section of the seventh rib and 
such offensive pus escaped that almost all 
the students left the lecture room. Ee- 
ferring to what Dr. Oartledge has said 
about the case just reported : I made the 
same remark at the time of the operation. 
However, I thought it was best to try it 
with the resection of one rib, and if I 
failed to get closure, then do the operation 
he refers to. 

I saw m Edinburgh, in 1886, a case 
that had been operated upon by Annan- 
dale for empyema which had existed for 
years, and it seemed to me that he removed 

the greater part of one side of the thorax. 
He made an incision very low down and 
removed fully four inches of the tenth 
rib, a little less of the next and so on un- 
til the apex reached about the third rib. 
He told me he had operated on several 
cases iR that way and had gotten excellent 

De. a. M. Caetledge: Do you not 
think the odor, where the empyema has 
been the result of original pneumonia, is 
because of the fact that air has been in- 
troduced from the lung? I have seen 
several cases of this kind. 

De. W. 0. EoBEETS: I am satisfied 
that there was communication with the 
lung in this case. Before the operation 
this man expectorated large quantities of 
pus that looked tuberculous in character. 
I am very sorry that I did not have a mi- 
croscopical examination made of it before 
this meeting. Since operation, expectora- 
tion has diminished very much. 

One peculiarity about this patient is 
that he has the most marked " club fin- 
gers " that I ever saw. 


De. a. M. Van"CE: I would like to men- 
tion a case of empyema that I saw the other 
day. I was called by Drs. Eudell and 
Evans to see a little boy who had been 
sick for five weeks, beginning with pneu- 
monia and ending up with what was sup- 
posed to be pleurisy of large proportions. 
He remained on his right side with the 
arm extended above his head ; had been 
in this condition for about two weeks and 
unable to breathe comfortably in any other 
position. He was unable to turn over and 
all the windows had to be kept open in 
order that he might get sufficient air. 
"We first gave him some whiskey and a 
hypodermic injection of nitro-glycerine, 
which improved his forces a little, and I 
found the whole right lung dull. I in- 
serted an aspirator needle and drew off 
about an ounce of pus, then the needle 
became obstructed. I then determined to 
open the chest without any anesthesia. I 
made an incision fully three inches long 
and inserted two large size drainage tubes; 
about a gallon of pus escaped, much of 
it being caseous in nature. As soon as 
about half of the pus was removed, the 
boy became very cheery and seemed mach 

July 29, 1898. 

Society Reports. 


The point of interest in the case is that 
the prolonged pressure seemed to have 
produced complete anaesthesia of the whole 
side. I would have washed out the cavity, 
had it not been for the fact that the boy 
was so much exhausted that I could not. 


Dr. a. M. Oartledge : I do not think 
we are justified in taking the additional risk 
in washing out the chest in these cases. 
In the first place, you have a large purulent 
sac that cannot be thoroughly cleansed by 
irrigation,, and T think the attempt is at- 
tended with danger. If it were possible 
to render this whole surface aseptic, then 
we might afford to take the additional 
risk. No matter how thoroughly you 
empty an empyema sac, when the dress- 
ings are changed you will find them satu- 
rated with pus, I believe the best plan is 
to introduce the shortest drainage tube 
that will reach the cavity, not attemping 
to get to the bottom, then apply an anti- 
septic dressing and let the drainage take 
care of itself. In my opinion we will 
shortly have an entirely new pathology of 
empyema. Pleuritic effusion becoming 
purulent, simply means the introduction of 
infection through the lung ; that most of 
these cases of pleuritic effusion follow as a 
result of pneumonia is beyond question. 
It is a well known fact that in the tuber- 
culous variety, no mattter what means of 
drainage you employ, the patient usually 

Don't Pick them Green. 

Statistics are said to show that young men 
do not, on the average, attain full physical 
maturity until they arrive at the age of 
twenty-eight years. Prof. Scheiller, of 
Harvard, asserts, as a result of his obser- 
vations, that young men do not attain to 
the full measure of their mental faculties 
before twenty-five years of age. Better 
say thirty. A shrewd observer has said 
that '^most men are boys until they are 
thirty, and little boys until they are 
twenty-five " ; and this accords with the 
standard of manhood which was fixed at 
thirty among the ancient Hebrews and 
other races. A remedy is needed for the 
progress and propagation of puerility. — 

Dr. KLEiiq", the distinguished lecturer 
on physiology at St. Bartholomew's, has 
announced that science is enriched by a 
medical discovery as important in the 
domain of therapeutics as chloroform, 
laudanum and quinine. The great theory 
of infection by bacillus forms requires, in 
order to be fruitful of benefits to mankind, 
the discovery of a powerful germicide. 
In carbolic acid, in corrosive sublimate and 
in potassium permanganate, science has 
made long strides in the direction of ade- 
quate antiseptics and bacillicides, but these 
drugs all have their drawbacks. Now, 
however, Mr. Worrall, a noted scientist, 
claims to have found among the coal pro- 
ducts a disinfecting body apparently supe- 
rior to all previous ones. He has named 
it izal, and Dr. Klein, after a series of 
exhaustive laboratory experiments, is said 
to have found it absolutely destructive of 
the spores of some of the most intractable 
and malignant diseases. Unlike most 
powerful disinfectants, it is non-poisonous 
to human beings, and may be taken inter- 
nally, diluted. Dr. Klein's experi- 
ments go to prove that, diluted with 200 
parts of water, izal absolutely destroys the 
vitality of the microbes of diphtheria, 
scarlatina, glanders, erysipelas, typhoid 
and cholera. Black and White, in speak- 
ing of the discovery, says: "It is not too 
much to say that izal, unless the conclus- 
ions of one of the most competent of our 
physiologists are erroneous, is the |most 
important discovery in practical therapeu- 
tics made during the present generation." 

An Addition to Therapeutics. 

Mrs. Selby — ''Doctah, the chile dun 
gone swaller'r pint ob ink." 

Doctor — " Hab yo' dun ennyding fo' de 
relief ob 'im? " 

Mrs. Selby — " I'se dun made 'im eat 
free sheets of blottin' paper, doctah. 
Was dat rite?" 

It is hard to feel at home with people 
who never make mistakes. 

They had asked Dr. Sandblast, the 
eminent surgeon, to carve the festal fowl, 
and he stood over it with the carving knife 
delicately held in the first position. 
"The incision, you will observe, gentle- 
men," he began dreamily, " commences a 
little to the left of the median line, and — 
oh, excuse me^ Mrs. Parmalee, I thought 
I was in the — may I help you to a little of 
the femur ? " — Puck. 

The Medical and Surgical Reporter 



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NOTICE TO CONTRIBUTORS •.—We are always glad to receive articles of value to the profession, and when used they 
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make a note of that fact on the first page of the MS. It is well for contributors to enclose stamps for postage, that the- 
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Saturday, July 22nd, 1893. 



In 1884, Nicolaire {Deutsche Medical 
Wochenschrift^ No. 42, 1884), produced 
tetanus in certain of the lower animals 
by inoculating them with garden earth. 
He also showed that the disease could be 
transmitted to other animals by inocula- 
ting them subcutaneously with the pus 
from the infected animal. Later it was 
shown by Carl and Rattone that it was an 
infectious disease, and could be transmit- 
ted from man to animals by inoculation. 
The bacillus was isolated and obtained in 
pure culture by Kitasato in 1889. Tetan- 
us has been produced by a large number 
of investigators by inoculating animals 
with garden or field soil. So numerous 
haye been the cases of tetanus in man 
from injury, and the test inoculation 
of guinea pigs with soil, that the bacillus 
is now known to be very widely distribut- 
ed in nature. 

Morphologically, the bacillus of tetanus 
is an exceedingly interesting germ. It is 
a slender rod-shaped germ with one end 
rounded and the other usually much en- 

larged, and containing a spore. The spore 
appears at the end in the form of a little 
sphere, giving the bacillus the appearance 
of a short pin. The bacilli are from two 
to three micromillimeters in length. 
They stain with the aniline dyes usually 
employed in staining bacteria, and they 
retain their coloring matter when treated 
after the Gram method. They are motile. 
The bacillus of tetanus does not grow 
in an atmosphere containing oxygen. In 
anaerobic cultures it develops at the 
room temperature, but grows best at a 
temperature of about 36°C. It liquifies 
gelatine and solidifies blood serum. In 
an atmosphere of hydrogen it grows very 
rapidly in alkaline bouillon and in gelatine. 
The addition of glucose to the culture 
medium increases the rapidity of the 
growth. The spores of tetanus bacilli 
retain their vitality for several weeks in a 
desiccated condition. They also resist a 
temperature of 80°C. maintained for an 
hour. They are rapidly destroyed by 
boiling. Experiments have shown that 

July 29. 1893. 



when animals are inoculated with tetanus 
bacilli, either in pure culture or otherwise, 
that the bacilli remain at the seat of in- 
oculation and that death results from the 
action of poisonous substances elaborated 
by the growth of the bacteria in their 
place of injection. Kitasato has shown 
that cultures of the tetanus bacilli that 
were filtered through porcelain, which re- 
moved all of the bacilli, would produce the 
disease ; i. e. , symptoms and death. The 
result of certain European investigators 
show that this germ does not become at- 
tenuated by artificial cultivations. Biegor, 
Fraenkel and Kitasato have isolated a tox- 
albumin from cultures of the tetanus 
bacillus, which is very fatal. Much work 
has been successfully done in producing 
immunity in mice and guinea pigs against 

With the better knowledge of the dis- 
ease has come a better method of dealing 
with it, and we now have authentic re- 
ports of the healing of traumatic tetanus 
by the use of the antitoxin of tetanus, pre- 
pared by Lizzoni and Oattani. 

Schwarz {CentralMatt f. Bahteriologie^ 
X. 1891), reports a case of traumatic 
tetanus that was cured by the use of sub- 
cutaneous injections of an emulsion of 
antitoxin^ prepared from the blood of a 
dog that was immune to the disease. A 
boy of fifteen years was injured August 
20th. Early in September he showed 
symptoms of tetanus, and September 17th 
was taken to a hospital. He exhibited 
every symptom of tetanus. September 
18th, he received 15 grams of antitoxin; it 
was ground up in 3cc. of water and in- 
jected. September 19th, the injection was 
repeated in the morning and in the after- 
noon a second injection of 2 grams. Sep- 
tember 20th, a marked improvement in 
the symptoms, in the afternoon 0.25 
gram injected. September 21st, still fur- 
ther improvement, injection repeated. 
September 22nd, patient continued to im- 
prove; no injection. September 23rd, 

nearly recovered; the tetanus symptoms 
entirely gone. October 1st, the patient 
had fully recovered and was dismissed 
from the hospital. After each injection 
there was a depression in the temperature 
and after that a certain amount of per- 

Pacissi {La Reforma Medica, No. 4, 
1892), reports a successful treatment of 
tetanus with the antitoxin (prepared from 
the serum of an immunized dog). After 
eight injections of the antitoxin the symp- 
toms were relieved. 

Several other cases of similar success in 
the use of this substance are reported, but 
they all tend to the opinion that the sub- 
stance is practical and could be used with 
advantage in all cases of traumatic teta- 
nus. The preparation of the antitoxin 
requires a certain amount of care and 
knowledge of chemistry and bacteriology. 
The results that are being obtained with 
this and other substances, prepared either 
from cultures of bacteria or the blood of 
immunized animals, suggest the importance 
of state boards of health equipping them- 
selves with a laboratory and bacteriologist 
competent to prepare these substances for 
the needs of the physicians within their 

An Excellant Label Paste. 

The Nat. Dr. claims, is: 

T>- Potato starch i part. 

-Qa Water 3 to 4 parts. 

Solution of caustic soda enough to gelatinize. 

It is said this will not sour. 

For Laryngeal Phthisis. 

X' Union Medicale (in Therap. Gaz.,) sug- 
gests the following: 

T>. Iodoform gr. Ixxv 

x)6 Calcis phosphat pulv 5 iiss 

Acid boric, pulv 5 j 

Menthol gr. v 

M. Sig. Insufflate, morning and night, a sufficient 
amount into the larynx. For relief of difficulty in swal- 
lowing, or the irritation which may be present, it is well 
to use a swab wet with a solution of cocaine. 


LocAii Anesthesia may be readily produc- 
ed in about a minute by a spray of menthol, 
p. j ; chloroform, p. xv ; and will last from 
two or six minutes. 



Yol. Ixix 


Circnmscribed arteritis, according to 
Lancereanx {Le. Bull Med.^ March 29, 
1893), has for its principal characteristic 
the circumscription of the arterial lesion, 
its localization to a vessel of medium 
caliber, its termination bj obliteration or 
by aneurismal dilatation. It comprises 
three distinct varieties, syphilitic arteritis, 
tubercular arteritis, and embolic arteritis. 
The first two varieties, due to a general 
infection of the organism, are perfectly 
defined ; the third, produced by the 
action of a foreign body, is no less clear, 
notwithstanding its varied origin, in its 
manifestations and its evolution. 

Syphilitic arteritis is localized to the 
arteries supplied with lymphatic glands, 
and particularly to the cerebro-spinal 
arteries; whilst the other vessels and 
notably the large arteries, as the aorta and 
its principal branches, are slightly or not 
at ail exposed. Several authors, however, 
have described syphilitic lesions of the 
large vessels. Weber reports that he has 
seen tumors of considerable size developed 
in the thickness of the middle tunic of the 
pulmonary artery together with gummy 
tumors upon the skull and in the liver. 
The circumscription of this lesion favors 
syphilis, but it is necessary to investigate 
further its evolution in order to positively 
admit its specific origin. In a case 
reported by Virchow, that of a young 
syphilitic girl afflicted with interstitial 
nephritis and whose aorta was garnished 
with sclerotic plaques, Lancereaux does 
not hesitate to recognize, in spite of the 
age of the patient, the existence of ordi- 
nary atheroma. He finds the proof of 
this in the multiplicity of the lesions of 
the aorta and in the nephritis which 
accompanies them. Most of the other 
cases of alteration, or of aneurism of the 
aorta attributed to syphilis, have no more 
value than the preceeding, because they 
are not based upon the proper character- 
istics and a special evolution, but only 
upon the false adage : post hoc propter hoc^ 
if not upon the amelioration of the phe- 
nomena of aneurism subsequent to specific 

t Translated for The Medical and Surgical Repor- 
ter by W. A. N. Borland, M.D. 

treatment, as if this treatment could re- 
pair a destruction of the arterial wall. 
Lancereaux believes that a certain number 
of these cases have a malarial origin. 
The frequency of alterations and aneurism 
of the large vessels, in the British Army 
and Navy, has for a long time attracted 
the attention of the English military sur- 
geon. Welch concludes wrongly that this 
affection is due to syphilis. It should be 
remembered that the frequency of this 
affection is relatively' larger among the 
colonial troops who are much exposed to 
a malarial infection, and Lancereaux is 
led to believe that the frequency of 
aneurism in the English army is due 
neither to syphilis nor to alcoholism, but 
rather to paludism, a disease equally as 
common among the troops and which has 
a tendency to produce a special aortitis. 

The influence of syphilis upon the 
arteries, especially those of the cerebro- 
spinal centres is incontestable, these 
vessels, are in truth, the seat of predilec- 
tion of the action of the syphilitic virus, 
and the reason of this lies in the lym- 
phatic glands that surround them, for it 
is known that the lymphatic system is the 
avenue of the development of the mani- 
festations of constitutional syphilis. The 
lymphatic becomes enlarged and pressing 
externally and internally upon the middle 
coat of the artery, the latter atrophies, 
and the blood, pressing upon the thinned 
wall, produces a simple dilatation or a true 
aneurismal tumor. In the other cases, 
the syphilitic arteritis produces a narrow- 
ing or even an obliteration of the caliber. 
These are followed, in either case, by an 
ischemia more or less complete, and often 
a rupture of the vessel. 

Tubercular arteritis is relatively rare, 
but it likewise tends to become localized 
in the arteries of small and middle size 
and especially in those that possess a lym- 
phatic adventitia, as the lymphatic 
medium is necessary to the development 
of the cerebral arteries. It shows a 
special predilection for the cerebral 
arteries and especially for the branches of 
the pulmonary arteries. Histolgically, it 
consists in an infiltration of the arterial 

July 29, 1893. 



tissues with granalation tissue. The 
external tunic, the beginning point of the 
process, is filled with round cells (embryo- 
nal cells), forming islets more or less 
voluminous, which invade the normal tis- 
sue little by little and in which may be 
found the so-called giant cells. This 
tissue degeneration becomes necrotic and 
ulcerous, and thus eventually dilatation or 
aneurismal tumors are formed. This 
terminates by obliteration, aneurismal 
dilatation or by rupture. The aneurisms 
in the lung are usually found in cavities, 
are single or multiple, and may be 
mixed, saculated or varicose, in their 

nature. Tubercular arteritis is an insidious 
condition and one difficult to diagnose. 

Emholic arteritis has for its usual seat 
the branches of the pulmonary arteries 
and the cerebral arteries. The foreign 
body is surrounded by a development of 
embryonal cells due to the inflammation 
produced, a fibrinous clot forms and the 
calibre becomes obliterated by inflamma- 
tory action. The tunica intim takes on 
a vegetation and produces an endothelial 
bed and this tends to produce the oblitera- 
tion, which is the most common termina- 
tion. At other times ulceration occurs 
and aneurismal tumors are formed. 



The author. Dr. G. Lennander ( Upsala 
Ldharefbren Forhandl^hdi. xxviii, Hft. 1.), 
reports 34 operative cases, which were 
operated upon by him and his assistants 
between the fall of 1888 and summer of 
1892. There was but one death, which 
took place 5 weeks after the operation, 
caused by pyaemia, a small gangrenous por- 
tion of the intestines having been over- 
looked during the operation. In 3 cases, 
laparotomy with extirpation of the vermi- 
form appendix was performed, in which 
diffuse peritonitis existed. 

In 3 other patients, suffering from appen- 
dicitis, there were found 2 or more 
incapsulated intra-peritoneal abscesses, 
which were opened and drained; in only 

2 of these was it possible to remove the 
vermiform appendix; of these 3 it was 
found necessary to make incisions through 
the vagina] vault and the colon. 

In 12 cases, abscesses were found in the 
iliac fossa and in the lumbar region, and 
opened at those places; 3 times extirpa- 
tion of the appendix; of the 9 remaining, 

3 have had returns and there was 1 death, 
which has been reported at the beginning. 

In 7 cases laparotomy and amputation 
of the ulcerated or gangrenous appendix; 
operation 40 to 60 hours after the begin- 
ning of the attack with the exception of 
2, in which the attacks had lasted four 
days in one, and in the other nine days. 
Pelvic abscesses were present in 3 cases, 1 

^Translated for The Medical and Surgical Kepor- 
TER by Marie B. Werner, M. D. 

having discharged through the vagina and 
2 through the large intestine. Amputa- 
tion of the vermiform appendix was per- 
formed five times during the free inter- 
vals. Chronic appendicitis was diagnosed 
in one case, and operation revealed an 
abscess of the appendix, while the ad- 
hesions between the ileum and the 
anterior wall of the abdomen were dense ; 
these were released during the operation. 

As far as the author has been able to 
follow his cases, the patients are all well ; 
three still remaining under observation. 
During this time two patients who re- 
fused operation died of gangrenous ap- 
pendicitis; one had an inoperable carci- 
noma at the head of the colon and the 
other was supposed to be suffering from a 
perforating ulcer of the stomach, this 
presumably giving rise to the existing 
peritonitis. Etiologically, the author 
speaks first of foreign bodies or fecal cal- 
culi; the latter, according to his idea, 
forming in the appendix (not in the 
caecum as Talamon teaches) ; further, he 
believes in the possibility of a retention 
of the secretions, aided by the swelling of 
the mucous membrane, and particularly 
assisted by a bend or constriction of the 

The author has observed this in one 
case in which he operated, and later was 
able to palpate it in two cases before the 
operation. The primary stercoral typh- 
litis was observed by the author in several 
cases and he is therefore inclined to take the 



Vol. Ixix: 

opposite view of Sahli. Severe repeated 
attacks of appendicitis, in which the 
pathological changes have been entirely 
confined to the vermiform process, and 
suppurative peritonitis, in which there 
were only catarrhal changes in an unper- 
f orated vermiform appendix, were also 
seen by the author. Lennander prefers 
the rectal and vaginal examination. He 
has, in several cases, found the difference 
in temperature above the normal between 
the axillary and the rectal methods, 
which Madelung has found to be pathog- 
nomonic of suppuration in the lower por- 
tion of the abdomen or the pelvis. 

L. does not operate during the interval 
between the attacks, only at the express 
wish of the patient. He then opens down, 
releases all the adhesions which seem, to 
him, to be of pathological origin, and then 
invaginates the stump into the coecum. 
If diffuse peritonitis is present, a section 
is unavoidable, indeed strictly indicated. 
If the pus formed has become incap- 
sulated, he tries, if possible, to avoid open- 
ing into the free abdominal cavity and 
prefers to drain, and, with the aid of anti- 
septics, feels certain that this method is 
less dangerous than to allow an unopened, 
undrained pus pocket to re*nain in the 
pelvic cavity. 

His incisions are usually in the median 
line or laterally. If the latter, he directs 
his incision along the motor nerves, in 
order to avoid hernia. During the opera- 
tion, the author uses a warm solution of 
sodium chloride (sometimes 20 to 30 litres). 
If at all possible, the appendix is removed, 
and generally no intestinal suture is made, 
but he closes the opening by the application 
of Pean's forceps, which are left in the 
wound; drainage of iodoform gauze is 
used between the loops of small intestines, 
Keith's glass drain is also placed. The 
accumulative fluid is aspirated during the 
24 hours, once in 3 hours or oftener if 

Narcosis, at first chlorform by drops 
and later ether. The after treatment 
consist in small doses of morphia for the 
existing pain. To avoid symptoms of 
ileus, the stomach and intestines are wash- 
ed out ; nourishment is given as early as 
possible and in rapidly increasing doses. 
If necessary, warm enamata (500 to 600 
dr.) are given to check the thirst, once or 
twice daily. 

The continuance of even slight symp- 
toms of ileus is an indication, to the 
mind of the author, of more abscesses or 
of fecal accumulations. As a rational 
treatment in cases of relapses of peri- 
typhlitis, L. recommends careful massage, 
but only in the Doctor's hand ; this may 
also be the best method by which he will 
be able to gain thorough knowledge of 
the anatomical conditions present. — 
Centralb. fur Chir., 1893. 

The Effect of Smoking Tobacco on 

Among 32 school boys, who were exam- 
ined iby Decaisne, between the ages 
of 9 and 15, of whom all smoked, he 
found that 22 suffered from disturbances- 
of the circulation, of digestion, mental 
relaxation and decided taste for alcoholic 
liquors; 8 of these were suffering from 
anaemia and from intermittent pulse. — 
Der Kinder-Arzt 1893. 

A glasgow physician is the defendant in 
a curious breach of promise case. His 
courtship was progressing smoothly enough 
until his fiance requested his services for 
treatment of fistula. The trouble was of 
tuberculous origin. He treated the case,, 
but lost his affection for the fair but un- 
fortunate patient. Perhaps if he loses 
his case, he can offset the damages by a, 
bill for professional services. 

Pkof. Keen" says a good point to bear in 
mind in diagnosing a case of Chancre is 
that you will never find chancres on the 
walls of the vagina, as they always appear 
on its outlet. 

Prof. Hare says the iodide of potas- 
sium will be found to the best adapted, not 
to the acute stages of rheumatism, in which 
in the joints are generally very hot and 
painful, but to the sub-acute stages, in 
which the joints are swollen and the return 
to the normal condition seems to be very 

We are generally so carried away by the 
last words of famous personages, that we 
never pause to reflect that the first words 
of these same heroes were " goo, goo. 


t ". 


* Translated for The Medicaid and 
Reporter by Marie B. Werner, M. D. 


July 29, 1893. 




Little has been written on the normal 
measurements of the liver and their path- 
ological variations during infant life. 

The clinical measurements are relatively 
easy to make and to practicing physicians 
are of more importance than a knowledge 
of the various diameters and the weights. 

These last can never serve as a means 
of comparison between the conditions of 
health, of functional derangement and of 
serious pathological changes. It is not 
possible clinically to determine the abso- 
lute dimensions of the liver, because of 
its being surrounded by resonant viscera 
— the lungs and intestines. Clinical 
measurements are, however, of value if 
they show a regular progression according 
to age, their variations depending simply 
on passing troubles of digestion. The 
author quotes from Vogel, of Dorpat, and 
gives the description of clinical examina- 
tions which he has adopted. 

Physical examination of the liver is 
made in children exactly as in adults. 
Percussion in the axillary and mammary 
lines determines the measurements of the 
right lobe, and percussion in the vertical 
line through the sternum that of the left. 
Restlessness in little children makes this 
determination difficult. We generally 
cannot establish the influence of respira- 
tion on these measurements before the age 
of three years. The mammary and axil- 
lary lines are the only ones upon which 
Douchez believes percussion to be of prac- 
tical use. He has often, in cases of con- 
siderable hypertrophy of the liver, failed 
to find any evidence of increase in its pos- 
terior face by means of percussion on a 
vertical line drawn through the scapula. 
He believes that there are three causes of 
error in examination that are of especial 
hindrance in children. They are exces- 
sive resonance of the thorax, resistance of 
the abdominal muscles, and distension of 
the stomach and intestines by gas. The 
greatest source of error is the extreme 
resonance of the thorax, especially in the 

In spite of care, measurements on the 
living are commonly a little less than on 
the dead. This statement the author 

proves by a table showing the results of 
many observations. Nevertheless, although 
giving less liver dulness than similar ex- 
aminations after death, these results in 
the living represent really the impression 
given to the finger and ear ; and the error, 
if it be one, is reproduced uniformly and 
proportionately at all times. 

In certain cases, indeed, the demarcation 
of the upper and lower borders of the 
liver by percussion may leave doubt in the 
mind, and it is then well to verify by pal- 
pation. When the lower border extends 
abnormally low, palpation immediately be- 
low the false ribs encounters a certain re- 
sistance provided the child will relax his 
muscles. If, on the contary, he holds him- 
self tense, the finger meets with resistance 
at any rate; and it is well to repeat the 
observations several times in the same 

Percussion serves better than palpation 
to define the slender edge of the liver, 
which is easily displaced. This thin edge 
of the liver may be resonant to percussion 
on account of its thinness and its relations 
with the intestine ; and this occurs even 
after the abdomen has been opened. The 
child is best examined on his left side, 
the arm being raised, the hand grasping 
the bed and the left flank supported on a 
pillow. Percussion should be made on 
both the mammary and axillary lines ; the 
two observations serving as a control upon 
each other, for the upper line of dulness 
is practically on the same horizontal plane 
in both of them. 

In order to best show the relation of 
measurements, the writer has grouped his 
observations into three classes : 

1. Measurements on the cadaver before 
and after opening the subject. 

2. Measurements on the liver of the liv- 
ing in health. 

3. Measurements of the liver of the 
living in disease. 

The author presents a table of 88 ob- 
servations. He finds that in the greater 
number of infectious diseases, including 
even measles and diphtheria, it is not un- 
common to find enlargement of the liver, 
due probably to incomplete elimination of 



Vol. Ixix 

the poison. His conclusions are as 
follows : 

1. The exact determination of the 
borders of the liver in children is difi&cnlt, 
because of the involuntary contraction of 
irhe muscles, also on account of the 
resonance found over the thin lower edge 
and of the oblique position of the upper 

2. The measure of dulness of the an- 
terior face of the liver, in the living, is 
almost always less by one or two centi- 
meters than the real measure on the 
cadaver, either before or after opening the 
abdomen; we should therefore estimate 
this dulness from its extreme limits in 
order to reach as nearly as possible to the 

3. The upper border of the liver 
corresponds in general to the interval 
between the fifth and sixth ribs. 

4. In the healthy state, the vertical 
measurements increase almost regularly 

with each yearns growth, excepting in 
certain individuals. 

5. This appreciable growth between 
the second and ninth years ceases almost 
entirely by the twelfth year and can be 
measured in centimetres by adding one, 
two or three centimetres, an additional 
centimetre for every year of the child's 
life up to eight years exclusive. Beyond 
eight or nine years the liver dulness 
measures approximately nearly, but not 
quite, one centimetre for each year of the 
child^s life. 

6. The liver was found somewhat large 
in cases of catarrhal jaundice and gastric 
disturbance; large in cardiac disease, very 
large with amyloid liver, syphilitic liver, 
fatty liver and hydatid cysts. 

7. The slightest disturbance of health 
may cause a variation of two to four 
centimeteres, and a variation of three to 
ten centimetres was found with certain 
grave lesions. — Douchez: Revue Mensuelle. 


Mr. Torald Sollmann, a registered 
pharmacist of Ohio, for the present resid- 
ing in Paris for the purpose of the pur- 
suit of special branches of study, writes 
home to friends a very interesting account 
of some experiments aud demonstrations 
in the manufacture of artificial diamonds, 
which we are kindly allowed to reproduce. 
He says: 

"Yesterday I saw the biggest thing 
here yet. One of the fellows at the lab- 
oratory gave me an entry ticket to a lec- 
ture on diamonds by Prof. Moisson, of 
the School of Pharmacy. Several months 
ago, he first succeeded in making artificial 
ones, the first real diamonds ever made; 
former ones all turned out to be quartz. 
The lecture lasted an hour, and it took 
place in the big amphitheater of the Arts 
and Metiers Building. There was not a 
vacant space in the room, even the stairs 
were occupied. The lecture was illus- 
trated by experiments which were the 
most interesting part, something I don't 
suppose I will ever see again. The pro- 
fessor started out by saying that the dia- 
mond and the other forms of carbon were 
chemically identical. To prove it, he 
burned some lampblack in a tube through 

which a current of oxygen was passing, 
and conducted the carbonic acid into 
limewater. Then he burned a diamond. 
It was done in a platinum tube heated by 
a Bunsen burner, in a current of oxygen, 
the carbonic acid being also conducted 
into limewater. The image of the inter- 
ior of the tube was thrown on a screen, 
by means of a stereopticon, and we could 
see the little diamond gradually disappear. 
Then he further proved the identity of 
diamond and graphite by placing a dia- 
mond in the electric arc, when it was 
changed into graphite. Then he told us 
the difference between the various forms 
of carbon, that it depended upon the 
molecules combining among themselves. 
The diamond crystalizes in octohedra, the 
graphite in hexagons, the other forms are 
amorphous; the diamond scratches the 
ruby and can, when in fine powder, be 
separated from graphite by a liquid of the 
specific gravity of 2.3, in which the latter 
floats, whilst the former sinks. This he 
also illustrated. Then he came back to 
his subject proper. When he took up the 
subject of producing the diamond arti- 
ficially, he started in by studying the earth 
in which it was naturally formed. He 

July 29, 1893. 



found that all the earth, wherever fonnd, 
contained a large amount or iron. Here 
he exhibited a piece of diamond-bearing 
clay from the Cape. Then he gave an ac- 
count of his experiments. He brought a 
mixture of carbon and iron to an intense 
heat. Here he described the furnace he 
employed and showed it. It produces a 
heat of 3500°O. (6300°F.) It is formed 
by an electric arc with 400 amperes, in- 
closed in a furnace of lime, which is the 
only substance capable of withstanding 
that temperature. Well, he heated his 
mixture, and obtained graphite. For 
two years he kept on experimenting, sub- 
stituting gold, silver, nickel, manganese, 
chrome, and everything else, and he in- 
variably obtained graphite. It began to 
dawn upon him that something else was 
necessary and that something was pres- 
sure. About that time they discovered a 
meteorite which contained microscopic 
diamonds, identical with the microscopic 
ones found in large numbers in all the 
diamondiferous clay. This put him on 
the track, for iron possesses the property 
of contracting in passing from the liquid 
to the solid shape. In producing this 
change suddenly, the pressure produced 
by the solidifying outer envelope on the 
still liquid inner mass is something enor- 
mous, and any carbon inclosed in it will 
be subjected at the same time to a high 
degree of pressure and heat. And that is 
the way he makes his diamonds, which he 
now proceeded to do, or rather several as- 
sistants did it. The iron containing car- 
bon was placed under the arc in the fur- 
nace already described and the current 
turned on. The lime is such a good non- 
conductor that he could place his hand on 
it two inches from the place where the 
temperature was 3500°C. That is the 
highest temperature possible to obtain 
with our present means, as then the car- 
bon of the electrodes begins to volatilize. 
After melting it for a while, the cover was 
taken from the furnace, the crucible 
(burned to a white heat, so intense that 
the operators had to wear blue spectacles), 
was lifted from it by forceps, and planged 
into a jar of cold water. Plunging iron 
of 6300°F. into cold water is rather a 
dangerous experiment and enthusiasm 
ran high. I can^t explain the phenomena 
which took place. It did not make much 
noise and no spurting, but for a time a 
good sized flame was over the water. 

After a minute he took it out again and 
let it cool gradually. He then performed 
the same experiment with carbon and sil- 
ver. After cooling they are treated with 
hydrochloric and nitric acids respectively, 
the graphite separated from the diamonds 
by means of sp. grav. and it is finished. 
We did not see that part of it, it would 
have taken too long, but he showed us 
by the stereopticon, first, the diamonds of 
the meteorite, then his artificial ones. 
The largest is 3-10 of a milimeter in 
diameter. At present it will be im- 
possible to make them ' handsomer and 
larger,^ the conditions of heat and pres- 
sure being unrealizable, but at least 
we can make diamonds. — The Pliar. 

Scrotal Eczema. 

The following is recomnaended {Memphis 
Med. Mo.)'. 

T>, Hydrarg. chlor. mit 5i 

-Qy Zinc oxidi gr. xl 

Bismuthi subnit 5iss 

lyanolin Bi 

Vaseline Sss 

M, Ft. ung. 

Sig. — Wash the scrotum in hot borax water, and apply 
the ointment night and morning. 

Spice Plaster. 


Powdered capsicum, 

Powdered cinnamon, 

Powdered cloves, of each, 2 ozs. 

Rye meal, 


Honey, of each, a sufficiency. 
To be make into a cataplasm by trituration on a plate, 
and spreading upon a close fabric. It should be made up 
extemporaneously when required. 


Sodium salicylate, in doses of three grains 
every two hours/is said to be very efficacious 
in relieving urticaria. Three or four doses 
usually suffice for a cure of the most obstinate 
ease.— it/ed. Beeord. 

Hardening and Coloring Plaster of Paris 

First dry the casts in an oven heated to 
about the temperature used in baking bread. 
After they have cooled so that they can be 
handled without burning the hands, immerse 
them in a strong, clear solution of alum, and 
let remain until the alum commences to crys- 
tallize on the surface. Remove and wipe off 
the alum with a wet rag, and again dry in a 
warm(not hot) oven. When entirely dry im- 
merse in boiled linseed oil cut with a little 
turpentine. When this is nearly dry apply 
bronze powder of the desired hue. — iVa^^. 


Curf'ent Literature. 

Vol. Ixix 



for July. Dr. A. D. Blackader contributes an 
article on the 

Etiology of Tuberculosis. 

In regard to the influence of heredity, the 
author states that it is the very rare exception 
to meet with hereditary tubercle, meaning 
thereby the congenital transference of the 
virus, so that the infant enters the world 
with the bacilli in its tissues. In the vast 
naajority of cases, heredity in tuberculosis 
signifies only "an excessive hospitality for 
the tubercle microbe, or a deficient capacity 
for dealing with him on the part of a too fee- 
ble phagocyte." 

It may be said, then, that the view gener- 
ally held at present in regard to the heredi- 
tary character of tuberculosis is that cases 
of true heredity are extremely rare, but that 
instances may occur where the mother is 
suffering from general miliary infection,, or 
from definite tuberculous disease of the gen- 
ital system. 

In reference to acquired infection, there 
are three paths by which the bacilli may ob- 
tain entrance: (1) By inhalation through the 
respiratory tract. (2) With the food through 
the alimentary tract. (3) By inoculation. 
Of these perhaps the most important is the 
first — by the inhalation of dust containing 
the bacilli in a dried state. These bacilli ap- 
pear to have great powers of resistance, and 
are able to retain their infective powers for a 
long period of time. While in a moist state 
they do not appear to escape from the 
sputum, but when the sputum becomes dry 
it is readily converted into dust, and the 
bacilli are then liable to be diffused through 
the air. Great care should therefore be taken 
over the expectoration of tuberculous pa- 
tients, that it be thoroughly disinfected as 
soon as raised and afterwards destroyed, else 
the apartments occupied by such patients be- 
come infective in time through such dust 
clinging ,to carpets, bedroom hangings, etc. 
Not only may the living apartments become 
infective, but business ofiices and railway 
carriages, and even the dust of the road-side 
become a source of contagion. 

The .predilection of the apices to 
the occurrence of symptoms indicative of 
the presence of the bacilli is well 
recognized. This predilection has been 
explained on several theories; among 
others, it has been referred to an im- 
perfect expansion of the apex or to defective 
circulation. Recently, it has ibeen pointed 
out that the thorax at the apex lacks con- 
tracting muscular tissue, and with forced ex- 
piration there is a recurrent passage of air 
into the upper lobes, interfering with the ex- 
pulsion of any foreign substances that may 
have entered the bronchial tubes. When 
they have once entered this part of the lung, 
they experience an amount of rest, which 
enables them to penetrate to the sub-epithe- 
lial tissues and enter the lymph canals. 

This penetration generally takes place in the 
alveoli, where the epithelium is non-ciliated, 
rather than in the ciliated passages of the 
smaller bronchi. 

While, in adults, inhalation of the bacilli 
and infection through the respiratory tract is 
much the most frequent origin of tuberculo- 
sis, in children the alimentary tract affords 
an important path through which the bacilli 
effect an entrance into the system. The 
upper part of the tract, owing to the very 
frequent disorders of the throat, mouth and 
teeth, occasionally becomes the place of pri- 
mary infection from which the bacilli pass to 
the cervical and sub-maxilliary glands, and 
thence may occasion general infection. 

Dr. G. E. Armstrong reports 

Five cases of Abdominal Section after Con=' 

In the first case, fever came on after the 
patient got up on the tenth day. The symp- 
toms increased in severity till an operation 
was demanded for relief. At the section the 
uterus was curetted, swabbed out with a solu- 
tion of permanganate of potassium and 
packed with iodoform gauze. The omentum 
was found adherent to the uterus and left tube 
and, on separating the adhesions, a pus sac 
was discovered, which was emptied, the 
ovary and itube tied off and part of the 
omentum removed. The patient made a 
good recovery. 

The second case had been attended by a 
midwife and, at the section, one tube was found 
enlarged to the size of an adult's wrist and 
contained small pockets of pus. The ovary 
was of natural size and gangrenous. 

In the third case, the trouble seemed to 
follow the administration of an enema. 

" At 10 o'clock in the evening of the ninth 
day, the nurse decided that her patient's 
bowels needed moving. As the baby had a 
little looseness the nurse though that an 
enema was the proper thing to give. The 
patient objected strongly to this, on the 
ground that after her first confinement she 
had anenema and that she suffered very great 
pain for 48 hours afterwards. Her objection, 
however, was overcome and the enema was 
given. She was almost immediately seized 
with intense abdominal pain, with great 
general tenderness, and vomiting. She had 
a small stool almost immediately and her 
bowels did not move afterwards. The vomit- 
ing persisted and soon became bilious. 
Hypodermics of opium were given to relieve 
the pain. The abdomen became tympanitic, 
the temperature rose, the pulse became rapid 
and shabby, the face became drawn and 
anxious, and it was evident that the patient 
was suffering from some severe lesion, 
sufficient to cause a condition of collapse. 
The history and symptoms pointed to some 
acute obstruction of the bowels, possibly a 
volvulus. Her condition was an extremely 
grave one, and it was easily seen that if any- 
thing was to be done more than had already 
been done, it was of a surgical nature. An 
exploratory incision was advised. 

July 29, 1893. 

Current Literature. 


The peritoneal covering of the intestines 
was congested and two pints of thin, pale 
yellow odorless pus flowed out. After 
thorough irrigation, the uterine appendages 
and appendix vermifornais were examined 
without finding any condition that was 
thought to bear a causitive relation to the 
peritonitis. The tube and ovaries were tied 
off. This woman was moribund when the 
operation was begun and died ten minutes 
after being removed from the table, or just 24 
hours from the giving of the enema land on- 
set of symptoms." 

In the fourth case the patient was siezed 
with severe pain, rigor and high temperature 
two months after confinement. At the sec- 
tion, a large tu bo-ovarian abscess on each side 
was found, The patient recovered. The 
author would teach the lesson, from these 
caseSjOf strict attention to antiseptic details in 
confinement and the immediate repair of all 
lesions occuring in child-bearing. 

This number of the magazine concludes 
with the report of the committee on tuber- 
culosis appointed by the Medico-Chirurgical 
Society. The following 

Rules for the Prevention of Tuberculosis 
are advised. 

1. For the safety of those around him the 
patient should only expectorate into 
cuspidors, and when not bedridden he should 
carry a pocket -spit-cup for use whenever in 
the house and places of public resort where 
there is no cuspidor available. A simple 
bedtoom cuspidor can be made out of a cup 
kept for this purpose alone, and half filled 
with water. 

2. To make sure that their contents do not 
become dried up, and so carried oflT as dust 
the cuspidors should contain water. Their 
contents should be poured daily in the sewer 
or cesspool (where the bacilli are soon de- 

3. Where the patient is up and about, and 
cannot employ cuspidors, handerchiefs must 
be used, which are changed frequently, and 
placed in boiling water so soon as they are 
done with. 

4. The soiled handerchiefs and bed linen of 
such patients must be kept apart from those 
of healthy persons, and must be well boiled 
in the process of washing. 

5. Unless the position of the patient render 
this an impossibility (and in this case, for the 
safety of the family, he should enter a hos- 
pital) the patient must sleep alone— preferably 
in a room by himself. 

6. Whether the patient is up and about, or 
whether he is confined to bed, the following 
points should be attended to with regard to 
the bedroom. 

(a. ) It should be sunny, well ventilated and 
free from dark corners. 

(6.) All articles which collect dust should 
be removed— any carpet present should be 
replaced by floorcloth. The curtains, if any, 
should be of light washing material and 
should be washed frequently in boiling 

(c.) The walls should be whitewashed, or 
covered by material that can be rubbed by 
damp bread or damp cloths. 

{d.) The floor, and the room in general 
should never be dry dusted, but should be 
cleaned by damp cloths, so as to prevent the 
dust flying about. 

(6.) After the death of a patient suffering 
from phthisis, the room and bedding should 
be most thoroughly disinfected. The walls 
should be given a new coating of whitewash, 
or may be repapered only after all previous 
coats of paper have been well dampened and 
then scraped off. The bedding and clothing 
of the deceased should be disinfected in the dry 
steam disinfector ; where possible, they should 
be destroyed. 


for July. The principal article in this 
month's issue is by T. Arthur Helme, M. D., 
F.iR. S. E., on 

The Relative Position of the Aseptic and 
Antiseptic Method in Midwifery. 

The author takes the position that re- 
liance on the antiseptic method lulls the 
practitioner into a false sense of security and 
the danger is that the principles of cleanliness 
are lost sight of. It is common, he says, to 
flnd that the nurse has given the douche 
without the least attention to the condition 
of the nozzle of the syringe, which is] often 
very dirty. Or, the vulva is protected by a 
napkin which, after lying in a bucket soaked 
with prutrescent fluids for hours, is gently 
rinsed off" in warm water, dried before the 
fire and applied.^Or, the practitioner uses the 
douche for the "purpose of destroying the 
germs for which his hands alone are respons- 
sible. The author next takes up the bacter- 
iological investigations in regard to the 
presence of pus-forming germs in the healthy 
vagina and, after quoting at length the opin- 
ions of various observers, unhesitatingly de- 
cides that the normal vagina contains noth- 
ing which can be detrimental to the patient. 

The details of aseptic midwifery are 
carefully gone into and rules formulated. In 
regard to the treatment of the patient after 
delivery, the author says. " The vaginal 
douche is just as useless and just as harmful, 
or more so, in a normal case, post-partum 
as ante-partum; therefore, shun it: and the 
less said about the intra-uterine douche the 
better. Indeed, a great deal too much at- 
tention is paid to the cleansing of the patient, 
and a great deal too little to the cleansing 
of the practitioner and nurse. If only 
half the nurse's energy were let loose upon 
her own and the doctor's hands, instead of 
being devoted exclusively to the squirting 
of the woman's internal parts, miore benefit 
would result." 

He regards the use of the perineal pad as 
of the greatest importance. It should be 
made of wool, absorbent, that all discharges 
may be taken up; sufficiently large, that the 
outer layers are never saturated. The pad 
should be composed of antiseptic material. 
It should be retained by a perineal bandage 
and changed at least every three to six hours. 

The author sums up his paper as follows: 



Vol. Ixix 

1. The vagina of the healthy normal preg- 
nant, parturient, and puerperal woman must 
be regarded as aseptic. Our object is to pre- 
vent inoculation during and after labor: to 
attain this object, we look to — 

(a) Thorough cleansing of the hands and 
arms and instruments, with attention to the 
clothes and infrequency of examination. 

(6) Healthy surroundings, pure air, ^clean 
sheets, thorough cleansing of the external 
genitals before and after labor. No internal 
douching: The use of the perineal pad. 

2. The vagina of a woman suffering [from 
chronic discharge is a priori to be regarded 
as septic; our object is to destroy the germs 
already present, and to prevent fresh inocu- 
lation. In addition to the above treatment, 
therefore, we must here make use of internal 
antiseptic douching, before,- during, and after 
labor, aiming at sterilization of the vagina. 

And among this second group of cases the 
author would include those to which we are 
called in emergency, or after they have been 
for hours, or, may be, for days, in the hands 
of a midwife, and those where labor has 
lingered for hours with continuous, body dis- 
charge or under other doubtful conditions. 

With our precautions there will, however, 
always remain a third series of cases where 
danger comes from a part not to be reached 
even by the douche — the tubes — cases difficult 
of treatment, and still more difficult of diag- 
nosis. But the question of vaginal 
antisepsis or asepsis does not materially affect 
these. Puerperal fever will occur, and its 
cause will probably be discovered post mor- 

The author wishes especially to condemn 
the unnecessary douching of the normal 
healthy woman ; thefaulty manner of douch- 
ing when thciunhealthy conditions necessitate 
itsiemployment ; use of imperfectly cleansed 
napkins. He would also urge that too much 
attention is paid to the disinfection of the 
patient and too little to the disinfection of 
the doctor and nurse. 

Dr. A. Graham Steell contributes a report 
of " A Case of Aortic Disease with Pulsus 
Bisferiens," illustrating the report with 
sphygmographic tracings of the pulse. The re- 
maining paper is a continued report on 
" Further Cases of Ovarian Cystic Tumors' ^ 
by Dr. D. Lloyd Roberts. 



The Use of Cocaine. 

1. Amount of cocaine used must be in 
proportion to extent of surface it is desired to 
anaesthetize. In no casei should the quantity 
exceed one grain and three-quarters. 

2. Cocaine should never be used in cases of 
heart disease, pulmonary disease, or in per- 
sons of highly nervous temperament. 

3. In injecting cocaine, the intradermic 
method is preferable to hypodermic. By in- 
jecting into, not under mucous membrane or 
skin, the risk of entering a blood vessel is 

4. During injection the patient should always 
be in recumbent position; in operations upon 
the nose and throat, the head should not be 
raised until anaesthesia is complete. 

5. It is of great importance that cocaine 
should be pure, since its combinations 
with certain other alkalies result in poisonous 
compounds. — Brooklyn Medical Journal. 


Half Rate Excursions to the World's Fair 
via Washington and the B. & O. R. R. 

The Baltimore and Ohio R. R. will run a 
series of special excursions from New York 
to the World's Fair at rate of §17.00 for the 
round trip. The trains will consist of first- 

class day coaches equipped with labatories 
and toilet conveniences. The trains will 
start from Jersey Central Station, foot of 
Liberty Street, New York, at 8.30 A. M., 
Aug. 5th, 9th and 15th, and reach Chicago at 
4.30 P. M. the following day. Tickets will 
be valid for outward journey only on the 
special trains, but will be good returning 
frona Chicago in day coaches on any regular 
train within 10 days, including day of sale. 
Stops will be made for meals at the dining 
stations on the line. A Tourist Agent and 
a train porter will accompany each train to 
look after the comfort of passengers. Tickets 
will also be sold for these trains at the Jersey 
Central offices in Newark, Elizabeth, Plain- 
field, Bound Brook and Somerville. New 
York offices 172, 415 and 1140 Broadway, and 
Station foot of Liberty Street. 

Picturesque Route to the Fair. 

No other line offers the variety of scenic 
interest between New York and Chicago that 
is enjoyed by World's Fair tourists via the 
Baltimore and Ohio Railroad. Passing 
through Philadelphia, Baltimore, Washing- 
ton, the capital of the nation, and by way of 
Harper's Ferry and the historic Potonaac 
Valley to the Allegheny mountains, which 
are crossed at an elevation of 3,000 feet above 
the sea, the traveler sees the arena of the 
activity of the nation as well as the principal 
historical features and scenic wonders of the 
East. Low rates. 

Vol. Lxrx, No. 6 
Whole No. 1901. 

AUGUST 5, 1893 

S5.00 per Annum 
10 Cents a Copy 



Established 1853, by S. W. Butler. M. D. 



AUG ^"^isy 

Entered as Second-Class Matter at Philadelphia P. O. 

P. O. BOX 843, PHILA, PA. 


H, F, Slifer, North Wales, Pa. 
The use of Milk in Health 195 


Dr. George M. Lefferts. 
Nasal Deviations 198 


A. Merill Rickets, M. D., Cincinnati, Ohio. 

The Early Removal of Tubercular Foci of Bone. . 200 
W. R. GooGE, M. D., Abbeville, Ga. 

Fracture of Skull, with Protrusion of Brain Sub- 
stance and Removal of same. .... 202 
M. L. Currie, M. D., Mt. Vernon, Ga. 

Periproctitis with an Abscess and Report of a 

Case 203 

W. L. BuLLARD, M. D., Columbus, Georgia. 

Headache versus Glaucoma 204 


The Clinical Society of Louisville 206 

The Medico-Chirurgical Society of Louisville. . 214 


Points of Similarity 215 

Anaesthetics 2I6 


Peritonitis Caused by the Proteus Vulgaris. . . 217 








ARMY AND NAVY ....... 232 




For Nervous Headache and Brain Fatigue. 



EJach dessertspoonful contains 

Salicylate Liithia, lO grs., 

and Bromide Soda, lO grs. 

A remedy in the treatment of 


Dr. A. Garrod, the well-known E)nglish authority on 
Gout, who was the first physician to introduce the Ivithia 
Salts in the treatment of the gouty diathesis, states that 
their action is materially increased by being adminis- 
tered in a freely diluted form 

This efifervescing salt of Lithia furnish an easy and 
elegant way of applying Dr. Garrod's methods. 





Useful in Nervous Headache, Sleeplessness, Ex- 
cessive Study, Over Brainwork, Nervous 
Debility, Mania, etc., etc. 

DOSE.— A heaping teaspoonful in halfa glass of water. 

It is claimed by some prominent specialists in nervous 
diseases that the Sodium Salt is more acceptable to the 
stomach than the Bromide Potassium. An almost cer- 
tain relief is given by the administration of this Effer- 
vescing Salt. It is also used with advantage in Indi- 
GBSTioN, Depression following alcoholic and other 
excesses, as well as Nervous Headache. It affords 
speedy relief for Mental and Physical Exhaustion. 



Mellin's Food 

A SOLUBLE DRY EXTRACT of Barley Malt and 
Wheat, for addition to Fresh Cow's Milk. 

Prepared upon the principles advanced by the 
eminent chemist, Baron Justus von Liebig. 

Experience — the supreme test — has absolutely 
proven that the best solution of the problem of infant 
feeding was made by Liebiq, and that MELLIN'S FOOD 
prepared with milk is the nearest approximation to, 
and is the BEST SUBSTITUTE for. Mother's Milk 
which has ever been devised. 

The Doliber=Qoodale Co., Boston, Mass. 



A^fU/fP I?ffUG- COMPANy 



Medical and Surgical 


No. 1901. 


Vol. LXIX— No. 6 



H. F. SLIFER, North Wales, Pa. 

The object of this brief paper is to pre- 
sent a few important data upon which to 
base the rational administration of cow's 
milk in health. 

Milk is a substance furnished and in- 
tended by nature as the sole food for the 
young of all mammals, and, for a con- 
siderable period of their existence, they 
feed upon it exclusively. It therefore^ 
represents a complete food, in which are 
present all the elements necessary for the 
nutrition and growth of the body. The 
various substances composing milk, and 
their relative proportions vary within com- 
paratively wide limits, not only in differ- 
ent races and breeds, but the milk of the 
individual is subject to extensive variation. 
Some of the causes are: age, period of 
lactation, nature and amount of food, 
time of feeding, state of health and the 
treatment of the animal, — scrupulous 
care and kindness should ever attend the 
milk-producing cow. 

It is stated on good authority, that a 
cow, if frightened, will lose a large per- 
centage of her butter fats for twenty-four 
hours. As showing the influence of the 
nervous system on the formation of milk, 
and controlling the relative proportions, 
also the total amount of solids : two years 
ago I attended a child in convulsions 
caused by the ingestion of unhealthy 
milk. On investigation, I ascertained that 
the milk had been secured from a cow 
that during the night had broken her 

"*Read before the Montgomery County Medical 
Society July 26, 1893. 

chain and gained access to a barrel of 
swill, from which she gorged herself. A 
few days since, I saw a child suffering 
from indigestion, fever and vomiting pro- 
duced by the taking of its mother^s milk 
which, later in the day, it refused. In 
this case, the milk was altered through the 
influence of emotional excitement brought 
on by an altercation with her husband on 
the subject of intemperance. 

It is evident that many conditions will 
influence the character of milk, varying 
in degree from a slight loss in the per- 
centage of some of its constituents, to a 
profound chemical change so that it 
becomes poisonous. 

In consulting the different authors, I 
find a marked discrepancy in the analysis 
of milk, showing conclusively that it is 
not uniform in its composition. Accord- 
ing to Foster^ milk contains : — 











The fact that human milk is poorer in 
proteids,fats and salts, is of practical im- 
portance when cow's milk is substituted 
in the feeding of infants. The chemical 
reaction of human milk is alkaline ; cow's 
milk neutral or acid. Human milk is free 
from bacteria; cow's milk contains numer- 
bacteria, when it reaches the 



1 Text Book on Physiology. 


Original Articles. 

Vol. Ixix 

sumer. Human milk is richer in sugar 
and water than cow^s milk. 

In the process of digestion, the casein 
of human milk coagulates in small floeculi 
in the stomach and is readily digested, 
Avhile that of cow's milk forms large and 
firm coagula which dissolves with diffi- 
culty in the gastric juice. In prescribing 
milk, it behooves to keep constantly be- 
fore the mind the above facts to assure 
success in the use of this important agent. 
I am of the opinion, that, with close study 
of each case on the part of the physician, 
and a reasonable amount of intelligence 
on the part of the mother or nurse, the 
cow^s milk can be so modified as to bear so 
close a resemblance to human milk, that 
ir. becomes applicable in a large majority 
of cases. 

Moreover, it has been conceded . by all 
the higher authorities that animal milk is 
the proper food for children during the 
period of growth and development. 

Prof. Henoch,^ of Grermany^says : "Oow^s 
milk is but the substitute for mother's 
milk during the entire period of infancy. 
I consider the administration of other sub- 
stances advisable only when good cow's 
milk cannot be obtained." 

J. Lewis Smith, ^ of Kew York, says: 
'^ Milk should be the chief article of food 
during infancy^ after the first year the food 
may be made of such consistence as to be 
given with the spoon." 

A. Jacobi,* of New York, says: " The 
substitute should be as near normal 
woman's milk as possible; and naturally, 
when the latter cannot be ' had, animal 
milks are selected." 

For the adult body in a state 
of health, milk is not a typical 
food. To furnish the required amount of 
carbo-hydrates, to supply potential energy 
for moderate labor, twenty pints would be 
required, which would give an excess of 
fats and proteids ; so large a quantity of 
fluid would interfere with the digestive 
function, and soon overtax the kidneys. 

The food for adults, therefore, must be 
more concentrated, and richer in the car- 

The most important use of milk in 
health, is in the feeding of infants and 
children. During this period, when the 
circulation and metabolism is most active, 

2 Lecture on Diseases of Children. 

3 Diseases of Children. 

4 Intestinal Diseases of Children. 

the tissues containing an excess of water, 
milk is peculiarly adapted for the nutri- 
tion of the body. 

To be successful in the use of milk, 
the following condition must be observed : 

1 , The quality of milk used. 

2, " quantity of milk used. 

3, " time of feeding. 

4, " manner of feeding, 

5, " proper dilution. 


Milk should be as fresh as possible, and 
preserved upon ice. If this is impractic- 
able, it should be sterilized and bottled and 
kept cool. If milk free from impurities 
and perfectly fresh can be procured twice 
daily, it is not always essential that it 
should be sterilized. Milk should have a 
sweetish taste. Neutral or but faintly 
acid in reaction. Sp. G-r. 1029. Should 
contain not less than 3 per cent. , nor more 
than 4}^ per cent of fats. The proteids, 
consisting of albunium and casein, should 
constitute about 4 per cent. The salts, 
consisting of phosphate of calcium, potas- 
sium and magnesium, potassium chloride 
with traces of iron and other substances, 
must also exist in a fair percentage. The 
fats and proteids are more subject to 
variations than other constituents of milk ; 
therefore, demanding the most careful at- 

In regard to the quantity of milk given 
at each feeding, much care should be exer- 
cised. I am convinced that more children 
are over fed, than underfed. We should 
ever remember the capacity of the little 
stomachs, designed to receive and digest 
the milk. 

According to the measurments of Dr. 
T. M. Eotch,^ of Bostom, "The capacity 

5Cyclop8edia of Diseases of children, Keating. 

of an infants stomach 5 days old is 25 
cubic centimeters, (7^ drachms). Two 
months, 120 C. (4 ounces). Twelve 
months, 300 0. C. ( 10 ounces). Two 
years, 740 0. C. (25 ounces). In regul- 
ating the amount of milk, a fixed rule 
cannot be adhered to in all cases, since 
individuals diiier in their capacity and 
physiological demands. I am guided 
somewhat by the following index : 

Age. Intervals. Amount. 

1 Month ) EJvery 2 hours ( i oz. 

2 Months V during the i ^ *' 

3 " ) day. ( 3 " 

4 " I Every 2}^ hours f 4 '* 

5 " V during the 1 5 " 

6 " S day. 16" 

„ I Every 3 hours ,' 6 " 

TO •< J- during the \ to 


August 5, 1893. 

Original Articles 


I feed as little as possible between the 
hours of 9 P. M. and 5 A. M., thus to 
enable the child and attendant ample time 
for sleep. Some children can do with one 
feeding, others demand food two or three 
times during the night. As the child 
advances in age, I decrease the night feed- 
ings, and prolong the hours of sleep. 

The manner of feeding resolves itself 
into the simplest possible mode. Infants 
under twelve months of age, should feed 
exclusively from the bottle. In selecting 
the fittings, avoid all ostentation ; I prefer 
a plain bottle with a short neck, with the 
proper capacity adapted to the age of the 
child, a plain rubber nipple with a small 
aperture. The child while nursing 
should repose in a comfortable position, 
and attended by a person who will remove 
the bottle as soon as the supply of milk is 
exhausted. Under no conditions, should 
the child be permitted to suck or play with 
the empty bottle. It should immediately 
be cleaned and placed in water, or water 
with the addition of soda or borax,until the 
next feeding. Milk should always be given 
at a nniform temperature, approaching 
that of the normal temperature of the 
stomach, about 100° F. 

In substituting cow's milk for human 
milk, it is important to modify the former, 
so as to more closely resemble the latter. 
In comparing the analyses of the two, we 
observe that the cow's milk is richer in 
proteids, fats and salts. Very naturally, we 
endeavor to reduce these elements to their 
proper percentage; this is accomplished by 
the addition of water, which reduces all 
the constituents in an equal proportion, 
even those that are already deficient; this 
necessitates the addition of such con- 
stituents. The water employed for 
dilution, should always be boiled to 
destroy all organic substances which it 
may contain. 

Water not only acts as a diluent, but 
alters the physical condition of the casein 
so as to render it more digestable, by pre- 
venting the formation of large coagula 
during peptogenic digestion. 

The degree of dilution neccessarily de- 
pends upon the composition of the milk, 
the age and condition of the child. The 
following is my rule for dilution: 

Age I Month I Part of Milk to 3 Parts of Water, 
" 2 months I *' " 2 ' 

"3 "2 " " 2 

"6 "3 " " 2 

"9 "3 " " I 

" 12 '* 6 " " I 

In case of indigestion, which is fre- 
quently due to an inordinate amount of 
proteids or fats, my experience has taught 
me that by increased dilution, and a re- 
duction in the quantity of each feeding, 
the child is soon restored to its normal 
condition. There are also cases in which 
the fats are poorly digested and cause 
fatty diarrhoea; under such conditions, a 
portion of the fats should be removed and 
the usual quantity of water added. 

Milk that has been properly diluted 
requires the addition of such elements as 
are deficient. Sugar should be added to 
the amount of two drachms to the pint. 
The kind of sugar which should be used 
is unimportant. It is natural to suppose 
that milk-sugar should be prefered, since 
it is a normal constituent of milk. Cane 
sugar, however, is less liable to undergo 
fermentation and is more readily digested. 
If a good quality of milk is used, it is 
seldom necessary to add cream; yet, in 
cases of constipation I have found the 
addition of cream to be beneficial. Owing 
to cow^s milk being more or less acid, the 
addition of an alkali is essential ; bicar- 
bonate of soda or lime water will meet 
this indication. If constipation exists, 
phosphate of soda or magnesia should be 
used. Authors frequently speak of ad- 
ditions of farinaceous substances. My 
experience with these agents has been un- 
satisfactory. They are useful only so far 
as their mechanical action on the milk 
and irritating influence on the bowels are 
desirable. They are objectionable for two 
reasons: 1st, they differ too materially 
from normal milk elements; 2nd, they 
are difficult to digest. During early 
childhood the peptogenic functions pre- 
dominate ; the diastatic functions are not 
fully developed until later in life; and 
not until these two functions are equally 
balanced do we find vegetable matter 
properly digested. These substances 
undergo a more radical chemical change 
during digestion than animal substances. 
Since the peristalis in children is more 
active and the bowel comparatively short — 
according to Treves: "^ the length of the 
small intestine at birth is nine feet, and 
the colon one foot,^' — the food does not 
remain sufficient time in the bowels for 
perfect solution and absorption of vege- 
table substances. 

In children of naturally feeble digestion 
it is necessary not only to modify the milk 


Clinical Lectures. 

Vol. Ixix 

by dilution and additions, but to pre- 
digest it to a degree that the most delicate 
stomach will retain and digest it. This 
is accomplished by the use of a digestion 
ferment, either pepsin or extract pan- 
creatis. So far as my experience goes, I 
prefer the pancreatis, its peptoiniz- 
ing action is more energetic and 
capable of digesting every form of food. 
The casein is so altered as to resemble 
human milk and is regarded by 

Dr. Albert R. Leeds as humanized milk. 
In conclusion, as soon as the profession 
recognizes the importance of this subject, 
and exercise the same care in the selection 
and administration of milk that we exer- 
cise in the selection and administration of 
drugs; and more fully appreciate the 
appeal that is made to us year after year 
by that gigantic infant mortality, so soon 
will we reach a consummation most 




GrEi;rTLEME]S^ : — Nasal deviations may 
be divided into three great classes, viz : 
(1) Those due to severe crushing injuries, 
such as the kick of a horse, which belong 
to general surgery; (2) angular, curved, 
and sigmoid deviations; and (3) out- 
growths from the nasal septum. 

Setting aside the extreme cases of crush- 
ing injury of the nose, we come to a class 
of cases in which the injury may have 
occurred within the memory of the 
patient, but more frequently has happened 
so long ago that he does not recollect it at 
all. Rest assured, however, that some- 
where in life- time of that patient if he have 
a nasal deviation, there has been an injury 
to the nasal septum. Probably when he 
was but a very little child, he has fallen, 
and the injury has been done at this time, 
and has not attracted any attention. 

The septum should be a perfectly 
straight, thin, cartilaginous partition 
between the two nasal passages. The first 
form of injury to which I shall ask your 
attention is angular deviation. 

On one side, you will notice a cartila- 
ginous and bony projection, reaching well 
out into one nasal passage, and in the 
other nasal passage, there will be a con- 
cavity. The next form is known as 
curved deviation. In this, the bony sep- 
tum is bowed out into a large curve, which 
is thin and quite resilent. Here, again, 
in the one passage there is a projection. 

^Professor of diseases of the throat and 
College of Physicians and Surgeons, New York. 


and in the other, a corresponding con- 
cavity. The third or sigmoid deviation., 
is rather more difficult to diagnosticate. 
This diviation always involves both the 
cartilaginous and bony portions of the 
nasal septum. 

These are the three forms which are 
commonly seen, and which are the only 
ones you need remember. In almost 
every case, these deviations have been 
produced by some injury at a remote 
period. All three forms give rise to nasal 
stenosis. The first result of a blow on 
the nose in childhood will be chronic 
hypertrophic rhinitis, a condition which 
requires years for its development. The 
deviated septum and the hypertrophic 
rhinitis together produce a severe stenosis, 
and as a result of this obstruction, the 
patient is deprived of the sense of smell, 
his voice is harsh and muffled, and his 
hearing is defective. This last condition 
is due to the fact that the chronic 
catarrhal process has extended through 
the Eustachian tubes, or, as a result of 
the constant rarification of the air in the 
middle ear, the external pressure con- 
stantly drives the drum inward, and this, 
with the chronic resulting hypersemia, 
makes the patient more or less deaf. 
Secretions lodge upon the irregularities of 
the nasal passages ; they are removed by 
the patient, and an abrasion or ulcer is 
the result; and is very commonly asso- 
ciated with recurrent epistaxis. In such 
cases, always look on the side of the nasal 

August 5, 1893. 

Clinical Lectures, 


septum near the front, and yon will often 
be rewarded by finding the origin of the 
bleeding. Let me repeat — as a result of 
the nasal deviation, there will be mouth- 
breathing, chronic pharyngitis, chronic 
laryngitis, occlusion of the nasal passages, 
loss of resonance of voice, epistaxis, and 
dry, inpacted secretions. 

The sigmoid deviation is a comparatively 
rare form requiring special operative skill, 
and often a multiplicity of instruments for 
its proper relief ; so, in order not to unduly 
complicate this subject, I shall exclude 
this from consideration, and shall ask your 
attention only to two common forms of 
nasal deviation — the angular and the 

With the Adams forceps, the nasal 
septum is grasped firmly, and twisted in- 
to place, and maintained in this new posi- 
tion by means of intra-nasal plugs during 
the healing process. It is a most uncom- 
fortable treatment, and the results are 
most unsatisfactory. Another method of 
operating is with the stellate forceps, an 
instrument which makes a stellate incision 
through the curved deviation. This en- 
ables you to place the septum in the median 
line with much less force, and then the 
after-treatment is carried out with the 
intra-nasal plugs as before. The operation 
is theoretically very good, but the treat- 
ment is very annoying, and the results do 
not seem to me to justify its use. 

Another operation consists in using a for- 
ceps which will punch out several pieces from 
the nasal septum in the portion of greatest 
convexity. You may undoubtedly by this 
means clear the nasal passages, but you 
have left a communication between the 
nasal passages, a condition which is almost 
certain to prove uncomfortable to the 
patient all his life time. A simpler, much 
more comfortable, and effective operation 
consists in introducing a long brass pin 
through the curve in such a way as to hold 
it approximately in the proper position. 
This process may be facilitated by mak- 
ing two or three slight incisions into the 
septum. This pin can be worn without 
great inconvenience to the patient until 
the septum no longer tends to return to 
its former abnormal position. This is the 
.best method of treating curved devia- 

An angular deviation is best treated by 
sawing ofi or cutting off the obstruction 
under cocaine anaesthesia. In doing this. 

you must be careful not to make an open- 
ing into the adjoining nasal passage. 

We must next consider out growths 
from the nasal septum — exostoses or en- 
chondromata, if you please, There has 
been a blow on the nose which has most 
often driven the cartilaginous septum 
against the articulation of the vomer with 
the maxilla. This has resulted in a very 
slow perichondritis, and the slow forma- 
tion of a cartilaginous or osseous tumor. 
The differential diagnosis is made from 
angular deviation by observing that there 
is no corresponding concavity in the other 
nasal passage. Hypertrophic nasal catarrh 
will occur in every case where there is a 
deviation or projection of the nasal septum. 
In this third class is to be found the most 
frequent causes of nasal occlusion, and 
also the simplest method of removing the 
obstruction. The operation is performed 
either with a nasal saw, or with the nasal 
trephine, driven by an electric motor. 

A Taste for Science. 

Little Dick — " I know how to tell how 
deep a well is without going down." 

Father — '' Ah, I'm glad to see my son 
has a taste for science. You drop in a 
stone and count the number of seconds 
required for the descent, I presume? " 

Little Dick — "Oh, no, I tie the stone 
to a string and then measure the string." 
— Good News. 


Le Progres Medicale recommends the fol- 
lowing in otalgia: 

T> Camphorated chloral 5 parts. 

-Qy Glycerine 30 " 

Oil of sweet almonds 10 " 

Dip a tuft of cotton into this and introduce it into the 
patient's ear. 

For Migrane. 

The following is recommended: 

T>- Butyl-chloral hydrat grs. xv. 

x^ Tinct, cannabis indicse mxv. 

Tinct. gelsemii mxxx. 

Glycerin fSiv. 

Aquse ad f Siij. 

Mix. Big.— An ounce to be taken at once ; to be 
repeated in half an hour. 

If a Child Die in the Uterus, Prof. 
Parvin says, the mother will not manifest 
any unfavorable symptoms unless air enters 
the uterus, in which case putrefaction 
will take place with all its unfavorable 
symptoms, particularly diarrhoea and 



Vol. Ixix 


B. MERILL RICKETS, M. D., Cincinnati, Ohio. 

It is not my intention to address yon at 
any very great length, or present to yon 
a subject upon which no thought has been 
given by the surgeons in general. My 
intention is to present some evidence that 
may lead us to make an earlier diagnosis 
and to adopt more prompt and radical 
measures in tuberculosis of the bones than 
are generally adopted. Tuberculosis is 
one of the greatest enemies which the 
human body encounters. It is surely the 
greatest destroyer of its bony anatomy. 
When once the f rame^ or any part thereof 
becomes diseased, the interest of all that 
is dependent upon it, becomes jeopardized. 
Syphilis has been accredited as the great 
destroyer of not only one, but of all kinds 
of tissue. It is a blessing compared to 
the ravages which tuberculosis produces, 
for in syphilis we have a remedy without 
much surgical interference. In tuber- 
culosis, our hands seem to have been tied, 
and the wheel of progress in its treatment 
been made to stand still. There seems to 
be no constitutional treatment whatever of 
the least benefit in tubercular disease of 
the bones. It is not because there has 
been no effort, for medical literature has 
been flooded with the various remedies 
suggested for its cure. It seems now that 
tuberculin has fallen short of oar expecta- 
tions, failing in every particular, and 
giving no good results whatever. To my 
mind, the good to be obtained is through 
surgical interference only, and it then de- 
pends upon early operative procedures. 
Aseptic surgery has been the greatest 
boon to this class of work, and we must 
necessarily rely to a great degree upon 
cleanliness. However, we see how difficult 
it is to secure primary union even in the 
extirpation of tubercular glands. Seeing 
how hard it is to overcome these obstacles 
and to secure primary union in opera- 
tion upon the soft tissue, we must 
necessarily shrug our shoulders when we 
come to the extirpation of tubercular dis- 
ease of the bones and joints. However 

•■-Read Before Mitchell Dist. Med. AssociatioD, 
Baden Springs, Ind. 

much I might be gratified to present this 
subject to you voluminously, I must con- 
fine myself to the early extirpation of the 
tubercular foci in the bones. I believe 
that surgeons in general are responsible 
for a large per cent, of the cripples as the 
result of tubercular disease, and I am 
thoroughly satisfied that there has been 
too much delay, and that we have expected 
nature to do what we ourselves should have 
done. My own plan has been to act 
promptly and radically where I have evi- 
pence of tubercular disease of either the 
shaft or epiphysis. Even where there is 
a question as to the identity, it is best to 
give the patient the benefit of a doubt and 
operate promptly. In nearly all of the 
cases where the periosteum is thickened 
and tender, we have reason to suspect the 
presence of tuberculosis. Even in cases of 
trauma, tubercular bacilli seem to find 
their way and develop rapidly in the in- 
jured tissue. When once they are im- 
planted, they are not long in manifesting 
themselves and giving evidence of their 
presence ; therefore, it is in just such cases 
as these, especially of the long bones, that 
an exploratory incision and early extirpa- 
tion give such excellent results. It is a 
matter of course that one should hesitate 
to open a joint as promptly as he would 
a shaft, but unfortunately the shafts are 
not so frequently attacked as the epiphyses. 
It is a great question, and one which must 
be considered greatly from the light of ex- 
perience, as to the time when a joint 
should be opened ; however, I am safe in 
saying that the disease should be removed 
earlier when it attacks the epiphysis than 
when the shaft alone is involved. If the 
foci are thoroughly removed, let them be 
upon the surface or in the body of the 
epiphysis, then the destruction of bone is 
much less and its ability to repair itself 
much greater. Then too, when early 
extirpated, the possibility of the other 
bones being involved is lessened; the 
disease, when confined to 07ie foci, is not 
so rapid in its progress as where several 
are to be found, although the single one 

August 5, 1893. 



may be as large as several of the smaller 
ones combined. Then too, the greatest 
number of tubercular foci are found in 
the epiphysis because of its spongy nature. 
There is not so much liklihood of the foci 
being multiple in the shafts, because they 
are more compact. 

I do not believe that there is one foci in 
a thousand that undergoes spontaneous 
recovery, let it be in the shaft or epiphy- 
sis ; much less is it likely to recover when 
found in the epiphysis. Even rest, which 
has been so long considered a cure for 
tubercular joints, is of but little avail, 
giving to my mind, no evidence whatever 
of the reparative process as the result. 
When once an area has become attacked by 
the bacilli, there seems to be no limit to 
the destruction which it may produce. If 
they do not become multiple, the one will 
in the course of time destroy all the adja- 
cent tissues. Tuberculosis of the epiphy- 
sis is what epithelioma is to the skin, and 
should be looked upon with as great con- 
sideration, and the treatment' made as 
radical. The earlier an epithelioma is 
removed, the greater the chances for a 
permanent relief. Just so with a tuber- 
culous area within the bone. The in- 
fluence of the diseased area seems to be 
nothing more than that of a foreign body, 
except that the disease is more rapid and 
progressive. The opening of a joint free 
from any disease could result in nothing 
more than a certain amount of ankylosis. A 
joint affected with tuberculosis, necessar- 
ily results in ankylosis to a greater or less 
degree. ^NTow, is it not better in cases 
where there is every indication of tubercu- 
lar deposit, to give the patient the benefit 
of a doubt in exploratory incisions, fol- 
lowed, if necessary, by the removal of 
tuberculous matter? Until recently it was 
almost a crime to open the abdominal 
cavity. Now it has become quite a com- 
mon occurrence, even though doubt exists 
as to what is to be found within that 
cavity. Just so with tuberculosis of 
shafts, and especially joints. What can 
we expect from any other than radical 
treatment? The development of large 
ovarian tumors does not now occur, simply 
because the gynecologists have become so 
skilled in making early diagnoses that 
procrastination can no longer be attribu- 
ted to them. It is to be hoped that sur- 
geons who are called upon to treat the 
various forms of tuberculosis, especially of 

joints, will not delay radical operative 
procedures until there is great derstruction 
of bone, accompanied by the formation of 
fistulae. This is deplorable, and I think is 
largely due to the surgeon himself. Per- 
haps he does not early recognize the dis- 
ease, or it may be due to his inclination 
to procrastinate, or his fear in assuming 
responsibility, but it is as unscientific to 
allow the head of the femur to become 
destroyed from tuberculosis, as it is to 
allow an ovarian tumor to grow until it 
weighs 50 or 75 pounds. It is one thing 
for the patient or other influences to be 
responsible for such a state of affairs, and 
it is another for the responsibility to rest 
upon the attending physician. Just how 
much of the adjacent bone should be re- 
moved with tubercular foci, is a question 
for the operator himself to decide. I have 
no doubt but that, in the majority of hip- 
joint cases, the disease has progressed to 
a greater degree than is generally sup- 
posed at the time it is presented for treat- 
ment. We must expect all degrees of 
progress in the destruction of bony tissue 
as long as the people are isolated and out 
of reach of surgical aid. Poverty and 
indifference are prominent factors in the 
delay of treating all classes of disease, but 
this should not be of any influence in 
establishing laws. Let the rules be 
established, and the good results made 
known, and there can be no plausible 
reason why the application should not 
become general. 

A paste which will stick anything is 
said by Professor Winchell to be made as 
follows: Take two ounces of clear gum 
arable, one and one-half ounces of fine 
starch, and half an ounce of white sugar. 
Dissolve the gum arable in as much water 
as the laundress would use for the quantity 
of starch indicated. Mix the starch and 
sugar with the mucilage. Then cook the 
mixture in a vessel suspended in boiling 
water, until the starch becomes clear. 
The cement should be as thick as tar, and 
kept so. It can be kept from spoiling by 
the addition of camphor, or a little oil of 
cloves. — Pacific Med. Journal. 

Freckles can be removed, according to 
Hager, by the application every other day, 
of an ointment composed of white pre- 
cipitate and sub -nitrate of bismuth, each 
5i; glycerine ointment gss. 



Vol. Ixix 


W. R. GOOGE, M.D., Abbevillr, Ga. 

It is only recently that intrusion on ttie 
brain and membranes has been attended 
by so small a morality ; but, owing to the 
great success and progress which has been 
achieved in antiseptic surgery, it is now of 
common occurrence. 

It is not the purpose of this paper to 
let new light into the subject of brain 
surgery, but simply to corroborate the fact 
that if thorough cleanliness and strict 
astiseptic precautions are strenuously ob- 
served, the time will come and to a certain 
extent now is, that the surgeon may pene- 
trate the most secluded recesses of the 
human mechanism and perform wonders 
which were not long ago shrouded in ob- 

The time has been, and not long ago, 
when the idea was prevalent that intrusion 
on the brain or membranes was attended by 
almost certain death, or to penetrate the 
abdominal walls and peritoneum was con- 
sidered folly of the most aggravated type, 
but thanks to the promulgators of anti- 
sepsis, we can now with impunity perform 
operations of this nature with a very low 
per cent, of mortality, which none dare 
to dispute. It is a boon to humanity and 
should be a source of self-congratulation 
on the part of every physician. 

Fracture of the cranium with protru- 
sion of brain substance and removal of 
the same, with recovery, is now regarded 
among the laity and also among some of 
the practitioners of medicine, as an impos- 
sibility, and it is the intention of the 
writer to disclose the results of a case of 
this discription and to show, if any doubt 
exists, that recovery in such instances is 
of very common occurrence. 

On December 18th of last year, Mr. A. 
B. Pemberton, while guarding convicts for 
the Ocmulgee Brick Co., at Abbeville, 
Ga., was struck with the eye of a common 
club axe, on the posterior portion of the 
skull near the articulation of the occipital 
and parietal bones, the blow resulting in a 
complete fracture with the bone depressed 
and resting in the brain substance. The 
depressed bone had loosened quite a quan- 

-Read before the Georgia State Medical Association, 
April 19, 1893. 

tity of the brain, which, after observing 
the usual antiseptic precautions, I very 
carefully removed. It weighed just a little 
over half an ounce. After carefully re- 
moving every particle of matter that could 
possibly be foreign, I raised the skull with 
a common elevator to its proper position 
and placed it in apposition, after which I 
dressed the wound with iodoform gauze, 
packing the wound in order to prevent its 
healing externally; after which he was 
carried home and put to bed. Strange to 
say, he could walk and talk sensibly, still 
he had no recollection of the matter after- 

December 19th. Temperature 100° F. 
Absence of sensation, not being able to 
feel the prick of a pin ; mind wandering. 
Gave sulphate of quinine and ordered 
an enema warm soap-suds and water every 

December 20th. Temperature 101° F. 
Slight sensation; able to talk but would 
lose the subject. 

December 21st. Temperature 100° F. 
Sensation returning and complaining of 
pain in left arm. Wound was right side 
of head. 

December 22d. Temperature 90V F. 
Pain more severe on left side. Sensation 
almost restored. Gave hypodermic of 
morphia and atropine. 

December 23d. Pain gone. Sensation 
restored, and appetite good. Had eaten 
nothing since injured, being very much 
nauseated all the time. 

December 25th. Temperature normal. 
Dressed wound and, strange to say, found 
no pus whatever. Patient able to sit up 
for dressing wound. 

December 27th. Patient walked up 
town a distance of one-quarter of a mile, 
contrary to my directions. 

January 1 st. Bone had healed and re- 
moved packing from wound. 

January 5th. Wound granulating 

January lOtli. Discharged patient with 
the wound almost well. 

January 28th. Patient thoroughly 
well and accepted a position on S. F. & 
W. R. R. as section master. 

August 5, 1893. 



The question might naturally arise, 'are 
you sure that you removed the brain sub- 
stance ? And in reply I would say, that 

I never was surer of anything in my life, 
and can corroborate every assertion by my 
associate. Dr. A. R. Royal. 


M. L. CURRIE, M. D., Mt. Vernon, Ga. 

Periproctitis is one of those infrequent 
inflammatory diseases which the general 
pra'ctitioner may at any time be called to 
treat, and which he may fail to recognize 
until much damage to his patient ensues. 
If properly diagnosed, it may then be im- 
properly treated, owing to the fact that 
he cannot always find such a precedent as 
he needs. 

It is usually suppurative in character, 
but a cure may be effected by absorption, 
even after a distinct tumor is formed. 
Of the causes of this disease but little can 
be said. It may result from traumatism, 
foreign bodies, extension of adjacent in- 
flammatory processes, or any structural 
disease involving the mucous membrane 
of the rectum. The manner of its exten- 
sion and the course of the morbid pro- 
cesses excited, are identical with those 
seen in perityphlitis following typhlitis. 

The prognosis depends much upon the 
time when the case is diagnosed, the 
treatment of both the inflammation and 
the abscess as well as the physical condi- 
tion of the patient. When the vitality is 
low, and the abscess high up in the pelvic 
cavity, or when the patient is tuberculous 
it is unfavorable; when otherwise, we 
may hope for recovery. The diagnostic 
symptoms and the treatment I will give 
in connection with the following case. 

Case I. Mr. G. B. A., aged 37, weight 
200 lbs., very muscular and stout. On 
the 26th of January last he applied to me 
for treatment, stating that he had 
" piles;" that he was going to visit a sick 
relative in North Georgia, and would be 
gone two weeks ; presuming that he knew 
his trouble, and without any examination, 
I gave him the usual prescription to regu- 
late the bowels and an ointment for the 

On the 18th day of February, I was 
called and found my patient in bed with a 

*Read before the Georgia State Medical Association, 

temperature of 102°, suffering with in- 
tense pain in and around the rectum; 
with tenderness of the whole pelvic region. 
On inquiry he gave me the following his- 

On the 6th day of January last, while 
in the act of defecating, a severe pain was 
felt low down in the pelvic cavity on the 
left side, which continued daily, and 
which was always worse when bowels 
moved or during exercise. During his 
entire visit the pain was incessant. The 
medicine prescribed by me failed to relieve 
him, and, while riding on the cars, he 
was unable to sit erect, owing to the pain 
it caused him. Having carefully exam- 
ined him, I found some induration of tis- 
sue and slight swelling, with heat and 
much tenderness, below Poupart's ligament 
on the left side. The sphincter muscles ap- 
peared to be spasmodically contracted and 
the tenderness around the anus was so 
great that I could not by the use of a 4 
per cent, solution of cocaine introduce my 
finger into the rectum. 

For this condition I advised rest in bed, 
and gave for the pain, morphine and 
atrophia hypodermically ; for the fever, 
phenacetine and quinine ; for the bowels, 
solution of sulphate magnesia with aro- 
matic syrup of rheubarb and enemata of 
warm water; for the tumor, I applied 
warm fomentations. 

February 19th and 20th the swelling in 
left side gradually increased until a tumor 
as large as a walnut could be distinctly 
outlined, for which I applied warm starch 
poultices every two hours. On the morn- 
ing of February 21st, I discovered that 
the tumor had greatly diminished. In 
the evening, with the assistance of Drs. 
McCrimmon and Summerlin, I made a 
careful examination, under an anaesthetic, 
both digitally and through a rectal specu- 
lum and could discover no signs of a 
tumor or abs(;ess except the inflammation. 
During the next three days, the inflamma- 



Vol. Ixix 

tion increased, the pain became more 
severe, attended with constitutional depres- 
sion and inability to urinate. 

February 25th, assisted by Drs. Eogers 
and Summerlin, I again ansesthetized the 
patient, and with difl&culty I felt the lower 
edge of a fluctuating tumor protruding 
into the bowel at the apex of the ischio- 
rectal fossa, which probably pressed upon 
the urethra and rendered it necessary for 
me to use the catheter to empty the 

With the index finger of my left hand 
resting against the edge of the tumor 
through the rectum, I passed a medium 
sized trochar parallel with the bowel 
straight up for four inches. The opening 
was then enlarged with a long bistoury 
and a pair of dressing forceps. Almost a 
half pint of foul looking pus escaped, 
having the odor of faecal matter. The 
abscess cavity was then cleaned out, and 
iodoform gauze introduced and the part 
dressed with absorbent cotton. From 
the time the operation was performed the 
abscess discharged freely until the 28th, 
at which time the gauze came out and 
with difficulty more was introduced, 
owing to resistance on the part of the 
patient. During this time the patient was 
restricted to fluid diet and a tonic of iron 
and arsenic with quinine administered. 
On March the 4th, I introduced a small 
rubber tube in place of the gauze, v^hich 
was necessitated by the healing of the 

On March 8th, the discharge had 
about ceased, and the opening to the ab- 
scess closed. The patient was suffering 
with pain, attended with fever and the 

presence of former symptoms, which in- 
creased until the 10th. At this time, as- 
sisted by Drs. Rogers and McLeod, I re- 
opened the abscess, with my finger re- 
moved all septa of broken down tissue, 
and washed out the entire abscess cavity 
with an antiseptic solution of carbolic 
acid. A soft rubber drainage tube was 
introduced and the parts dressed as be- 

The abscess discharged freely and 
patient slowly convalesced, but on March 
14th, it was discovered that the water in- 
jected into the rectum partly passed out 
at the tube through the abscess. 

At this stage of -the case my judgment 
was severely tried to decide whether to 
subject my patient, who was at this time 
very weak, the fourth time to the depress- 
ing effects of an anaesthetic and sever 
such important structures as existed, 
between the two openings, or wait for the 
abscess to heal and then operate for the 

At the suggestion of an experienced 
surgeon, I waited, and to my pleasant 
surprise my patient is now able to be with 
me in this city and is well of both abscess 
and fistula without an operation. 

I report this case hoping that, by so 
doing, I may be the means of relieving 
suffering humanity in similar cases through 
the agency of some one or more of my 
professional brethren. I believe it would 
have been better surgery for me to have 
opened the abscess through the rectum 
and I know it would have been better 
when I first opened the abscess to have 
made the incision larger and removed all 
septa of broken down tissue. 


W. L. BULLARD, M. D., Columbus, Georgia. 

"These medical sciences stand at a 
stay, and have done for years," so said 
Lord Bacon in the sixteenth century. 
But, could he step forward to-day and 
look over the literature that has been pro- 
duced and brought forward relative to my 
theme, I am quite sanguine that this rare 
philosopher would change his assertion, 

* Read before Georgia State Metical Association, 
April 21, 1893. 

partly at least to say that medical science is 
still a little slow in finding any one remedy 
as a certain relief for all kinds of head- 
ache, but it has reached the highest pin- 
nacle of fame as to cause. The wise men 
tell us of an anemic, an hyperemic, or 
congestive, a nervous or cerebral, the 
toxic, and the bilious or sick headache, 
all of which have an abundance of causes. 
The oculists say that most cases 

August 5, 1893. 



are caused from eye strain, but the gyne- 
cologist goes the eye specialist one better, 
and swears that nearly every case is re- 
flected from uterine or ovarian irritation, 
while not a few cases are doubtless caused 
from urethral contraction, and syphilitic 
lesion of the brain or nervous system, so 
says the genito-urinary surgeon, and the 
general practitioner knows full well that 
nine cases out of ten are caused from a 
torpid liver or a gastro-duodenal catarrh. 
Now, gentlemen, ignoring every form of 
which we have spoken, including the 
headache the most of us will have the 
morning following the banquet, I will 
proceed to tell you of the kind of head- 
ache I wish to call your attention to, 
which is a headache, or possibly more 
often called neuralgia, a pain caused from 
and a symptom of a most serious disease 
of the eye — glaucoma. We ' have the 
acute and chronic; in the acute the eye 
ball becomes red and very much inflamed, 
with a hard tension of the ball as to 
touch, a dilated pupil, deep anterior 
chamber, and a cloudy condition of the 
aqueous humor and vitreous body accom- 
panied with nausea and vomiting, at 
times pronounced as a bilious attack. A 
patient with this kind of headache or 
neuralgia, suffers at times with the most 
intense pain extending into the eye from 
the brow on the nasal side with an 
oedematous condition of the lid. In the 
chronic form, it sometimes runs its whole 
course without causing any excessive 
degree of redness or inflammatory con- 
dition of the ball, and the vitreous and 
aqueous humors are transparent, render- 
ing necessary an ophthalmoscopic exami- 
nation with which the pathognomonic 
excavation of the optic nerve may be 
readily seen; yet the patient at times 
suffers intense supra-orbital pain. The 
storm after a day or so may pass off, but 
is sure to return at shorter or longer inter- 
vals, and the intra- occular tension slowly, 
but surely, does its destructive work upon 
the optic nerve fibres until the '^ windows 
of the soul " are forever closed. In true 
supra- orbital neuralgia or, as it is designa- 
ted by the laity, ''sun pain," the suffering is 
quite severe, the ball red and the supra- 
orbital notch very sensitive to the touch, 
but the pain is paroxysmal, beginning in 
the morning after sunrise, increasing for 
a few hours, and gradually subsiding in 
the afternoon before sunset, to begin the 

next morning possibly a little later than it 
did on the preceding day. You will find 
the vision not impaired, the cornea clear, 
the pupil normal in size and readily re- 
sponding to the influence of light, which 
is not the case in the glaucomatous form 
of headache, and under the treatment of 
antipyrine, quinine and arsenic the 
paroxysm is soon checked or broken. 
While there is some similarity between 
the two diseases, the differential diagnosis 
is easily established, yet I am afraid that 
most physicians have no idea how many 
human beings are to-day from a mistaken 
diagnosis, groping their way with vision 
irretrievably lost, and the victim left as in 
Milton^s soliloquy. 

I only wish that I was able to protray to 
your minds the true realities of which I 
speak. In an effort to do so, allow me to 
quote from a lecture delivered at the 
Chicago Policlinic by that eminent Chicago 
oculist, Dr. F.C.Hotz: "Gentlemen,it is the 
fact that the severe neuralgic pain, and the 
violent gastric disturbances, induced by 
acute glaucoma, have been taken and 
treated for " rheumatic or malarial" neu- 
ralgia, while the ocular disease has not 
been recognized until too late. I have 
seen several cases of this mistake; one 
was an especially sad case which impressed 
me so much that I shall never be able to 
efface its picture from my memory. 
Though fifteen years have gone by since I 
have seen the unfortunate patient, her 
image is before me now as vivid and dis- 
tinct as if I had seen her yesterday. Two 
months before I saw her she had been 
seized with fever, nausea, frequent vomit- 
ing, and violent ])ain extending over the 
entire left side of the head. Her physi- 
cian pronounced her trouble to be gastritis, 
and ''sick headache," and when the old 
lady called his attention to the fact that 
her sight was getting poorer every day (and 
she could see with her left eye only ; for 
the sight of the right eye had been destroy- 
ed by glaucoma ten years) he assured her 
she need not worry about it ; that her sight 
would return as soon as the stomach 
trouble was cured, and the neuralgia in 
the head relieved. Having implicit con- 
fidence in her physician she believed his 
word, and though her sight soon had van- 
ished completely, she waited hopefully for 
the day when the darkness would be lifted 
again from h^r eyes, and patiently endured 
the constant, most violent headache, which 


Society Reports. 

Vol. Ixix 

robbed her of rest and sleep by day and 
night. For two weary months this poor 
woman suffered, and hoped ; but then her 
patience was exhausted and much against 
the will of her physician she went to consult 
an oculist. Poor woman ! it was too late. 
The continued high tension of glaucoma 
had done its deadly work upon the optic 
nerve too truly, and although the iridec- 
tomy effectually reduced the intra-ocular 
tension, and promptly relieved the patient 
of the terrible headache so that after the 
operation she could enjoy a good quiet 
sleep for the first time in eight weeks, the 
woman has never seen a ray of light since 
the awful result of a mistaken diagnosis. " 
'^ovf, gentlemen, I venture the assertion 
that there is not an oculist of any experi- 
ence, so to speak, who has not seen cases 
similar to the one just quoted, and I will 
quote from a letter bearing on this subject 
received since I commenced to write this 
paper. It is by Mr. J. M. Floyd, of 
Fayetteville, Ala., who says that: "I 
write you concerning my wife, who has 
been blind for two years. She is fifty- 
seven years old; in very good health. 
About three years ago she was taken with 
neuralgia in the head, which settled in her 
eyes ; the misery was very intense for some 
months, after which she became nearly 
blind. She lost all sight about six months 
afterward. I took her to an oculist who 
pronounced it glaucoma, and told her 

that he could do her no good." Now, I 
don^t know the cause of the delay in this 
case but am sanguine to say that had there 
not been a mistaken diagnosis the delay 
would not have happened, and to-day 
there would have been one less blind per- 
son groping about in the long dark night. 
May I ask why this mistaken diagnosis ? 
Is it from the fact that we become care- 
less in making our examination, and take 
too much for granted in what our patient 
tells us? In truth sometimes do we let 
the patient make the diagnosis? But who 
is responsible? The diagnosis is correctly 
made, the only remedy is the surgeons 
knife, and the sooner the iridectomy is 
done the greater the chances for the res- 
toration of vision. No known medical 
treatment, including Dr. Hammond's 
cerebrine and medulline, can permanently 
stay the disease. Physostigma and pilo- 
carpine will check the destructive ravages 
for a time, giving the afflicted some chance 
until the surgeon can be seen. Prepara- 
tions of belladonna, and erythroxylon 
cocoa which includes cocaine, should 
never under any circumstances be used 
in glaucomatous headache, and perma- 
nent good need not be expected from 
any treatment save an iridectomy, 
as advised by Dr. Grsefe some years 
ago, and which I must add, is one 
of the grandest triumphs of modern 



Meeting, April 18th, 1893. 

Dr. John G. Cecil, President, pro. 
tem. in the Chair. 




Dr. p. Gunterman: I have a speci- 
men here which is very small and seem- 
ingly very insignificant; still it caused 
the death of a baby. A woman came to 
my office about two months ago, who was 
then seven months advanced in pregnancy. 
The day previous to her visit to my office 

she sustained a severe fall; however, she 
said that she got up and went about her 
work not feeling any serious inconvenience, 
but from that time she has not noticed any 
movement of the child. As there were 
no distressing or unusual symptoms, I 
advised her to let matters take their 
course and await results. She went on in 
that way until about ten days ago, when I 
was called in the evening to deliver her. 
I found her in labor, the bag of waters 
protruding and the os well dilated; found 
a small head presenting ; ruptured the bag 

August 5, 1893. 

Society Reports. 


of waters and there was but a small 
quantity, 1^ pints to a quart all together, 
which was clear and not fetid. Delivery 
was accomplished without difficulty and 
the placenta came away promptly. I 
found that the baby was dead, probably 
at about the seventh month, but was not 
macerated. When I tied off the cord I 
noticed close to the body a shriveling of 
the cord ; upon closer examination I found 
this little specimen and cut it off. Evi- 
dently the child had died from the effects 
of the mother's fall, making several turns, 
twisting the cord close to the abdomen 
and the constriction thus produced stopped 
the circulation. 

P. Gunterman, M. D., then read a 
paper on 


At the previous meeting I had the 
pleasure of reading about the adminis- 
tration of chloroform. Purposely the 
anaesthesia from ether was not touched 
upon. Ether has been used by me com- 
paratively but a few times; chloroform 
quite frequently. And since these re- 
marks are made mainly to solicit discus- 
sion, there is no reason why the ether 
question might not be also discussed. 

The remarks this evening having been 
very hastily jotted down, only, to my 
mind, the most salient points have been 

Chloroform, if it does kill, does so 
either abruptly and suddenly or gradually 
and by degrees. Chloroform is an irri- 
tant specific narcotic, one of great dif- 
fusibility and capable of quick and exces- 
sive action. On the other hand it is pro- 
gressive in its action, and when ad- 
ministered in proper dose, gradually, 
the patient is not apt to die from an 
overdose, but if he does the end may not 
come so slow as from other narcotics and 
as from ether. 

A person to be chloroformed and made 
ready for an operation is naturally often 
unduly excited, because of the chloroform 
and because of the operation. Such a 
state of mind is very dangerous and great 
caution ought to be exercised less 
we have spasms of the respiratory 
muscles, failure of respiration from par- 
alysis or syncope. Death may come after 
the first few whiffs or later, sometimes 

even after the administration has long 
ceased and the patient is thought to be 
recovering. Strong, healthy and robust 
(especially stout) people who take chloro- 
form for the relief of pain from small 
troubles, are prone to have syncope. 
People otherwise constituted, when given 
chloroform for a short time and short of 
abolishing completely actual pain, do not 
often, if ever, have fatal syncope. 

We must, as stated the other night, pay 
close attention to breathing, pulse, the 
reflexes and the approach of cerebral 
anaemia. Danger is near from this last 
source when you notice a peculiar pallor 
of the face and particularly about the lips, 
which are firmly drawn, so as to expose 
the teeth, and give to the countenance a 
most ghastly expression. The operator 
may notice, before the chloroformist, that 
the patient is in danger when the 
flow from the bleeding artery stops. 
Change in respiration, faltering of the 
pulse, and unusual and persistent dilita- 
tion of the pupils are indicators of danger. 
It is said that a patient under the in- 
fluence of an anaesthetic is at the thresh- 
old of death, and a very insignificant peculi- 
arity of his may settle his fate. They do, 
however, not all die from the effects of 
the anaesthetic, at any rate conclusive 
proofs fail as yet. On the other hand 
people have died on the operating table 
who have taken no anaesthetic. A patient 
who dies while taking chloroform may die 
from other causes. 

Patients may die under anaesthesia 
from heart failure, by paralysis of the 
respiratory centers, from cerebral anaemia, 
and from shock. Deaths from heart 
failure and cerebral anaemia are perhaps 
the most frequent. If chloroform is to 
be blamed for all the mishaps ascribed to 
it, how do we explain the fact that, of the 
hundreds of thousounds of parturient 
women, who have taken it, not a single 
authentic fatal case is on record. It is 
claimed that their state of mind just fits 
them for taking the chloroform, that they 
just suffer enough pain to prevent syncope 
and that straining at every succeeding 
pain keeps the brain well supplied with 
blood. Such is good reasoning. We 
might, perhaps, conjecture that it is or- 
dained by an all-wise Providence, who is 
said to have condemned woman to bear 
her children in pain and agony. These 
facts ought to serve as proof, to an unbiased 


Society Reports. 


mind, that other agencies and conditions 
are at work to make chloroform — if yon 
will, any anaesthetic — a bugbear to the 
operator and cause unjust censure to the 
administrator for mishaps. 

If now accidents do occur, as they have 
done heretofore, be calm, be cool, be col- 
lected, and be deliberate. Have your 
means of resuscitation at hand. Have 
your stimulants, brandy, ammonia, nitrate 
of amyl and nitro glycerine, have your hot 
bottles and by all means your battery. 
Be ready to institute vigorous and pro- 
longed artificial respiration. Pull the 
chin forwards, upwards and with it the 
head backwards and forcibly draw the 
tongue forwards. If this mild form of 
artificial respiration does not succeed use 
any of the other established methods. 
Electricity is the great mover and stimu- 
lator of the respiratory muscles and 
nerves, and quite a number of cases are on 
record where its proper use brought about 
the desired result. Laryngotomy has 
been done to re-establish respiration. To re- 
lieve anaemia of the brain, reverse the condi- 
tion of affairs and put your subject in the 
l^erpendicular (almost) with the head 
down. Twice have I seen life come back 
in a body breathless, pulseless, and appar- 
ently dead. Men of worth have fought 
this method and others as warmly de- 
fended it. 

Permit me a little pleading for small 
stimulating doses of morphia, atropia, 
either — all things being equal — before or 
after the administration of chloroform. 
They may produce a general quietude, 
they may stimulate the heart's action and 
raise the blood pressure sufficiently, per- 
haps, to overcome undue depression from 
the chloroform. 

In conclusion: Whenever it becomes 
necessary to use means of revival be per- 
sistant, methodical and — keep on. 


Dr. Wm. Cheatham: It is a f